Every finding on record at Cabarrus Health and Rehabilitation Center

Based on record review, observations, and staff interviews, the facility failed to serve 3 of 4 meals observed (the lunch meal on 7/19/26 and the breakfast and lunch meals on 7/21/26) at scheduled mealtimes. This failure had the potential to affect all residents who received food by mouth on 2 of 2 hallways (Halls 100 and 200). The facility had a census of 115.Findings included: a. Review of the meal serving times provided by the facility for the lunch meal on 7/19/26 revealed the lunch trays were scheduled as follows:1st cart at 11:30 AM to the dining room2nd cart at 12:00 PM to the 200 hallway3rd cart at 12:15 PM to the 200 hallway4th cart at 12:30 PM to the 100 hallway5th cart at 12:45 PM to the 100 hallwayDuring an observation on 7/19/26 at 11:30 AM, no resident was eating lunch in the dining room. At 12:00 PM, lunch trays had not arrived at the 200 hallway. Further observation revealed that the only trays delivered to any hallway were the trays for the 100 hallway, which was the first lunch cart. The first meal cart to arrive at the 200 hallway was delivered at 12:45 PM.During an interview on 7/19/26 at 1:30 PM, Nurse Aide (NA) #1 stated the kitchen alternated delivery of trays between hallways. NA #1 stated that sometimes the 100 hallway received trays first and sometimes the 200 hallway received trays first. NA #1 indicated that trays were delivered late on occasions. and nursing staff usually checked the hallways to see which hallway received trays first.During an interview on 7/20/26 at 10:00 AM, the Food Service Director stated dietary staff alternated which hallway received trays first for each meal. b. On 7/20/26 at 10:30 AM, the Food Service Director provided the breakfast meal service time schedule. Based on review, breakfast trays were scheduled as follows:1st cart at 7:30 AM to the 100 hallway2nd cart at 7:45 AM to the 100 hallway3rd cart at 8:00 AM to the 100 hallway4th cart at 8:30 AM to the 200 hallway5th cart at 8:45 AM to the 200 hallwayTray line observation on 7/21/26 from 7:10 AM to 8:10 AM revealed only three dietary staff in the kitchen: the Food Service Director, Regional Dietary Manager, and Dietary Cook. The first breakfast cart to the 100 hallway did not leave the kitchen by 8:10 AM. During an interview on 7/21/26 at 7:15 AM, the Food Service Director stated two dietary aides who were scheduled had called out that morning. He stated he was working with the cook to ensure meals were prepared on time. He explained no other staff were available to come in because two dietary aides were on vacation, one had called in sick, and another was on bereavement leave.During an interview on 7/21/26 at 7:20 AM, the Regional Manager stated the Food Service Director notified him at 5:00 AM that two dietary aides had called out, so he came to assist. He stated he could call dietary staff from a sister facility if needed.Observation on 7/21/26 revealed that the first breakfast cart left the kitchen at approximately 8:20 AM and was delivered to the 100 hallway near the nursing station. Nursing staff began distributing meal trays from this cart at 8:23 AM. Additional observation on 7/21/26, conducted from 9:05 AM to 9:20 AM in the 200 hallway near the back area, revealed that nursing staff offered snacks and juice to residents waiting for their breakfast trays in their rooms and in the common area. Residents in the 200 hallway received their breakfast cart at 9:20 AM.During an interview on 7/21/26 at 9:40 AM, the Regional Dietary Manager was asked if additional staff were available to ensure lunch trays were delivered on time. Both the Regional Manager and Food Service Manager stated they did not need extra help and believed meals would be delivered on time.c. The lunch mealtime schedule for 7/21/26 was reviewed. Based on review of the meal serving times, lunch on 7/21/26 was scheduled as follows:1st cart at 11:30 AM to the 100 hallway2nd cart at 12:00 PM to the 100 hallway3rd cart at 12:15 PM to the 100 hallway4th cart at 12:30 PM to the 200 hallway5th cart at 12:45 PM to the 200 hallwayObservation revealed the first lunch cart for the 100 hallway was delivered at 12:45 PM on 7/21/26. Lunch carts for the 200 hallway were delivered at approximately 1:30 PM.During an interview on 7/22/26 at 8:57 AM, the Food Service Director stated the kitchen had 11 dietary staff, including three cooks and eight dietary aides. He stated he was waiting for two additional aides to complete background checks. He stated he was not understaffed and usually ran the kitchen on schedule. He did not believe meal trays were delivered late. He stated the kitchen usually had two dietary aides, one cook, and himself during both AM and PM shifts. He stated he was on vacation on 7/19/26, and the cook was in charge in his absence. The Food Service Director stated he informed the Administrator of the two call outs and that the Regional Manager was coming to assist.During an interview on 7/22/26 at 9:05 AM, Nurse #8, who was assigned to the backside of the 200 hallway, stated residents' meal trays were usually delivered late. She stated staff were never notified when meal trays were running late. Nurse #8 stated she checked diabetic residents' blood sugars around mealtime to ensure they were not hypoglycemic. Residents were offered snacks until trays arrived, and insulin was administered only when trays were delivered. She stated dietary staffing concerns contributed to trays running late.During an interview on 7/22/26 at 9:10 AM, Unit Manager #1 stated dietary staff never notified her or nursing staff when meal trays were running late. Nursing staff notified her when trays were late, and NAs offered snacks to residents until trays arrived. She stated insulin was not administered until meal trays were delivered.During an interview on 7/22/26 at 10:00 AM, the Administrator stated the Food Service Director notified her of two dietary staff call outs and that the Regional Director was coming to assist. She stated the Food Service Director did not inform her that meals would be delivered late. The Administrator stated she was not aware that meal cart delivery between hallways alternated. She stated the dietary department was a contracted service, and the Food Service Director should notify management when meal trays were running late so that nursing staff could be informed and diabetic residents could be checked and medications administered appropriately.

Based on observation and staff interviews, the facility failed to ensure food was stored, prepared, and maintained in a sanitary manner. The facility failed to label food stored for use and failed to discard expired food in the walk in refrigerator. The facility failed to ensure employees' personal food was not stored in 1 of 1 reach in refrigerator. Staff failed to keep the oven, stove, deep fryer, and ice machine clean and free of burnt food and food stains. In addition, the facility failed to keep trash containers in the kitchen covered, failed to store cleaning equipment away from clean dishes, and failed to discard chipped plates from the tray line. The facility also failed to maintain hot food on the tray line above 135 degrees Fahrenheit (F). These failures had the potential to affect the safety and quality of food served to residents.Findings included:1a. Observation of the walk in refrigerator with the Dietary [NAME] on 7/19/26 at 10:20 AM revealed: An eight ounce cup with no lid or label containing yellow orange food, A round clear plastic container of mixed cut fruit labeled Use by date - 7/18, A two gallon clear plastic bag containing five boiled eggs labeled opened 7/14 and use by 7/17, A round clear container with creamy yellow pureed food dated 7/15, A white container labeled cucumbers and onions, dated 7/11/26.During an interview on 7/19/26 at 10:22 AM, the Dietary [NAME] stated the unlabeled food in the Styrofoam cups was fruit and she was unsure why it was in the refrigerator without a lid or label. She stated the mixed fruit was intended for lunch on 7/19/26, however after reviewing the date she discarded it. She indicated the boiled eggs should have been used previously. She stated the pureed food was pudding and should be discarded. She indicated the cucumbers and onions should also be discarded. She stated all leftover food should be discarded within three days and must be labeled with an opened or prep date and use by date.During an interview on 7/21/26 at 2:00 PM, the Food Service Director stated all food placed in any refrigerator must be labeled and dated. He could not explain why the boiled eggs were not used earlier, stating boiled eggs were used almost daily for breakfast. He reported food could be stored between three to seven days depending on the food item and the label must include a use by date.1b. Observation of the reach in refrigerator with the Dietary [NAME] on 7/19/26 at 10:25 AM revealed a blue insulated lunch box, an insulated water bottle, and an opened 16 ounce water bottle three quarters full of purple liquid, all unlabeled.During an interview on 7/19/26 at 10:26 AM, the Dietary [NAME] stated the lunch box and water bottles belonged to dietary staff and should not have been stored in the reach in refrigerator. She reiterated that staff personal food items were not permitted in this refrigerator.During an interview on 7/21/26 at 2:00 PM, the Food Service Director stated employees' personal food should not be stored in the reach in refrigerator.2. An observation on 7/19/26 at 10:40 AM with the Dietary [NAME] revealed: The double door oven had dark brown burnt stains on the inside doors, shelves, and floor. A rack above the oven had dark burnt food stains. The oven had burnt food particles and white stains on the sides, The gas stove back splash guard and side splash guard had brown stains of oil and food on it, The deep fryer contained burnt food in the oil and on the fryer surface. [NAME] spots and burnt food and oil stains were present on the sides of the fryer.During an interview on 7/19/26 at 10:42 AM, the Dietary [NAME] stated kitchen equipment was cleaned per schedule and she was unsure of the source of the white spots.During an interview on 7/21/26 at 2:00 PM, the Food Service Director stated he personally cleaned the stove and dietary staff followed a cleaning schedule. He reported the oven was cleaned once weekly on Saturdays and the fryer was cleaned twice weekly.During a follow up walk through of the kitchen with the Food Service Director on 7/21/26 at 2:02 PM, the stove still had brown stains, the oven still had burnt stains, and the sides of the oven, stove, and fryer had white spots and food stains. The ice machine exterior had white stains. The Food Service Director could not state what the stains were or why these areas had not been cleaned according to the schedule.3a. Observation on 7/19/26 at 10:30 AM revealed a large black trash container without a lid placed near the dishwashing area and touching the ice machine. The trash container was half full and placed directly in front of the ice machine. The lid was found under the dishwashing machine. Staff were actively washing dishes. The ice machine was located on the other side of the wall of the dishwashing area.During an interview on 7/19/26 at 10:30 AM, the [NAME] stated the trash container should be in the dishwashing area and not near the ice machine.3b. Observation on 7/21/26 at 2:06 PM revealed meal tray carts containing dirty plates, cups, and utensils placed near and touching the ice machine.During an interview on 7/21/26 at 2:06 PM, the Food Service Director stated staff should not place dirty tray carts near the ice machine.4a. A continuous observation of the tray line on 7/21/26 from 7:15 AM to 8:10 AM revealed three of five divided plates were chipped and cracked and were set to be used for breakfast service.During an interview on 7/21/26 at 7:20 AM, the Food Service Director stated he would replace the cracked plates and that they may have been damaged during washing.4b. The temperatures of food on the tray line were taken by the Food Service Director using a calibrated thermometer on 7/21/25 at 7:36 AM. Observation revealed the following tray line temperatures: Pureed eggs: 121 F Turkey sausage patties: 122 F Pureed biscuit and gravy: 130 FAll items were below the required hot holding temperature of 135 F.The Food Service Director removed the items, reheated them, and rechecked temperatures at 7:53 AM and at 7:55 AM.During an interview on 7/21/26 at 8:00 AM, the Food Service Director stated he cooked the food to the recommended temperature, but the temperature might have dropped while the food was holding on the steam table and the tray line was set up. 5.Observation of the dishwashing area on 7/21/26 at 2:06 PM revealed a broom and long handled dustpan placed next to crates of clean cups and bowls, with the handles touching the clean dishware.During an interview on 7/21/26 at 2:06 PM, the Food Service Director stated a dietary aide had just swept the floor and must have placed the items there.During an interview on 7/22/26 at 10:05 AM, the Administrator stated leftover foods should be labeled and dated, including a use by date, and discarded within three days unless the product had a longer manufacturer approved shelf life. She stated staff should not store personal food in the reach in refrigerator, chipped plates should be discarded immediately, and all staff should follow the cleaning schedule, with the Food Service Director verifying compliance.

Based on record review, observations, resident, and staff interviews, the facility failed to notify the physician of missed medication administration for 1 of 7 residents reviewed for medication administration (Resident #77).The findings included:Resident #77 was admitted to the facility on [DATE] with diagnoses including diabetes and sleep apnea.Lab results for Resident #77 included a hemoglobin A1C (labs used to measure average blood glucose results over the past 3 months) dated 9/11/25 of 6.8 (normal 4.0-6.0). Lab results for Resident #77 included a hemoglobin A1C dated 5/29/26 of 7.1 (normal 4.0-6.0). Resident #77 weighed 362 pounds on 9/5/25.Resident #77 weighed 384 pounds on 6/9/26. A physician order dated 11/19/25 ordered tirzepatide (a once weekly injectable medication used for the treatment of elevated blood glucose levels and used for the treatment of sleep apnea and weight management) 10 milligrams (mg) once weekly on Thursday for diabetes.The Medication Administration Record (MAR) documented on 1/19/26 the medication tirzepatide 10 mg was not administered.A progress note written by Nurse #1 dated 2/19/26 at 8:40 AM documented the tirzepatide was reordered. There was no documentation the Physician been notified of the missed dose of tirzepatide and no order to hold the medication.A phone interview was conducted with Nurse #1 on 7/21/26 at 1:34 PM. Nurse #1 reported she did recall that she had not called the Physician and explained she should have called the on-call provider to report the medication was not given and gotten an order to administer when the medication was delivered.A physician order dated 2/27/26 ordered tirzepatide increased to 12.5 mg to be injected every Thursday.Review of the MAR revealed on 3/5/26, Resident #77 did not receive tirzepatide 12.5 mg. There was no progress note written by Nurse #2 to explain why she did not receive the medication and no documentation the physician was notified.A phone interview with Nurse #2 was conducted on 7/21/26 at 3:08 PM. Nurse #2 reported she did not remember why Resident #77 did not receive the tirzepatide on 3/5/26. Nurse #2 reported if the medication was not given, the medication was not available, but she could not recall if she reordered the medication. Nurse #2 explained she should have called the on-call provider and written a note, as well as gotten a physician order to administer the medication when it was delivered.The MAR documented on 4/2/26 tirzepatide was not given and the progress note written by Nurse #3 documented waiting on pharmacy. There was no note indicating the physician had been notified.A phone interview was conducted with Nurse #3 on 7/21/26 at 10:24 AM. Nurse #3 reported she had not called the physician to notify him the medication had not been administered on 4/2/26 and Nurse #3 was unable to explain why she had not called.The MAR indicated Resident #77 did not receive tirzepatide 12.5 mg on 5/21/26 and there was a progress note written by Nurse #4 that the medication was not in stock and was not administered.There was no progress note indicating the physician had been notified written by Nurse #4.Attempts were made to contact Nurse #4 for interview, and those attempts were unsuccessful.On 6/11/26 tirzepatide 12.5 mg was not administered to Resident #77 and Nurse #5 documented medication reorder in a progress note. There was no documentation the physician had been notified.A phone interview was conducted with Nurse #5 on 7/21/26 at 12:45 PM. Nurse #5 reported she had not called the physician and had not received an order to hold the medication. A physician order dated 7/4/26 for tirzepatide 12.5 mg to be injected every Saturday.Resident #77 did not receive tirzepatide on 7/18/26. A progress note written by Nurse #7 documented waiting on pharmacy delivery and there no progress note indicated the physician had been notified the medication was not administered.Attempts were made to contact Nurse #7 for interview and those attempts were unsuccessful.Resident #77 was interviewed on 7/19/26 at 11:18 AM and she reported she had been missing doses of tirzepatide for months. Resident #77 explained she did not mention this to the Nurse Practitioner because she thought the nurses had reported the missing doses. The Unit Manager was interviewed on 7/21/26 at 2:09 PM. The Unit Manager reported she was not aware the Physician or the Nurse Practitioner had not been notified of the missing tirzepatide doses for Resident #77.The DON was interviewed on 7/21/26 at 2:26 PM. The DON explained she had been in her position for 3 weeks and had no idea that Resident #77 was not receiving her prescribed tirzepatide or that the Physician or Nurse Practitioner had not been notified. The facility Physician was interviewed by phone on 7/21/26 at 3:49 PM. The Physician reported he was not aware of the missing doses of tirzepatide for Resident #77, and he would have expected to be notified of each missing dose.A phone interview was conducted with the Nurse Practitioner on 7/22/26 at 11:09 AM. The Nurse Practitioner explained she was not aware Resident #77 had not been receiving doses of tirzepatide and Resident #77 had not mentioned this to her during her visits with the resident. The Nurse Practitioner reported she expected to be notified of all missed doses of medication so she could determine when the next dose should be administered.The Administrator was interviewed on 7/22/26 at 2:50 PM. The Administrator reported she was not aware the missing doses of Resident #77's tirzepatide had not been reported to the Physician or the Nurse Practitioner. The Administrator reported she expected the Physician or Nurse Practitioner was notified of all missed medications.

Based on record review, observations, and interviews with resident, pharmacist, physician, Nurse Practitioner, and staff, the facility failed to protect a resident's right to be free from misappropriation of tirzepatide (a medication used for the treatment of elevated blood glucose levels, sleep apnea and weight management) for 1 of 3 residents reviewed for misappropriation of property (Resident #77).The findings included:Resident #77 was admitted to the facility on [DATE] with diagnoses including diabetes and sleep apnea. A physician order dated 11/19/25 ordered tirzepatide (a once weekly injectable medication) 10 milligrams (mg) once weekly on Thursdays for diabetes.Review of the pharmacy packing slip dated 2/24/26 documented 2 pens of tirzepatide 10 mg with 2 doses of medication per pen were delivered to the facility and signed by Nurse #10 as received on 2/24/26 at 12:42 AM.The Medication Administration Record (MAR) revealed Resident #77 received tirzepatide 10 mg on Thursday 2/26/26.A physician order dated 2/27/26 indicated Resident #77's tirzepatide dose increased from 10 mg to 12.5 mg to be injected every Thursday.The pharmacy packing slip dated 3/10/26 documented that 1 pen of tirzepatide 12.5 mg with 2 doses of medication was delivered on 3/10/26 at 1:24 AM. The signature on the receipt was illegible.The MAR indicated Resident #77 received tirzepatide 12.5 mg on Thursday 3/12/26 and Thursday 3/19/26.The pharmacy packing slip dated 3/20/26 documented that 2 tirzepatide 12.5 mg pens with 2 doses of medication per pen was delivered on 3/20/26 at 1:15 AM. The signature on the receipt was illegible.The MAR indicated Resident #77 received tirzepatide 12.5 mg on Thursday 3/26/26.On Thursday 4/2/26 tirzepatide was documented as not given and the progress note written by Nurse #3 indicated waiting on pharmacy.A phone interview was conducted with Nurse #3 on 7/21/26 at 10:24 AM. Nurse #3 reported she was aware that a lot of the time the tirzepatide was not available for administration, and she did not know why. Nurse #3 was unable to report the specific dates, but explained that at one time, the nurses were counting tirzepatide doses with the narcotic count, but that practice had not been done for a while.A pharmacy packing slip dated 4/2/26 documented that 2 tirzepatide 12.5 mg pens with 2 doses of medication per pen had been delivered to the facility on 4/2/26 at 8:29 PM. The signature on the receipt was illegible.The MAR revealed Resident #77 received tirzepatide 12.5 mg on the following Thursdays: 4/9/26, 4/16/26, 4/23/26, 4/30/26, 5/7/26 and 5/14/26. On 5/21/26 there was a notation by Nurse #4 that the medication was not in stock and was not administered.Attempts were made to contact Nurse #4 for interview, and those attempts were unsuccessful.A pharmacy packing slip date 5/21/26 documented that 2 tirzepatide 12.5 mg pens with 2 doses of medication per pen were delivered on 5/21/26 at 12:43 PM. There was no signature on the receipt.A physician order dated 5/22/26 indicated tirzepatide 12.5 mg to be injected on Friday 5/22/26.The MAR indicated Resident #77 was administered tirzepatide 12.5 mg on Friday 5/22/26.The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #77 to be cognitively intact. The assessment coded her to have received one injection during the look-back period, and she was taking hypoglycemic medications (medications used to control blood glucose levels).Lab results for Resident #77 included a hemoglobin A1C (labs used to measure average blood glucose results over the past 3 months) dated 9/11/25 of 6.8 (normal 4.0-6.0). Lab results for Resident #77 included a hemoglobin A1C dated 5/29/26 of 7.1 (normal 4.0-6.0). The MAR revealed on Thursday 5/28/26 and Thursday 6/4/26 Resident #77 received 12.5 mg of tirzepatide. On Thursday 6/11/26 tirzepatide 12.5 mg was not administered and Nurse #5 documented medication reorder in a progress note.A phone interview was conducted with Nurse #5 on 7/21/26 at 12:45 PM. Nurse #5 reported she remembered the tirzepatide was not available for Resident #77 on 6/11/26 and she called the pharmacy to request a refill. Resident #77 weighed 362 pounds on 9/5/25.Resident #77 weighed 384 pounds on 6/9/26. A pharmacy packing slip dated 6/12/26 documented the delivery of 2 pens of tirzepatide 12.5 mg with 2 doses per pen. There was no signature indicating receipt of the medication on the packing slip and no date or time delivered.The MAR indicated Resident #77 received tirzepatide 12.5 mg on 6/18/26 and 6/25/26. Resident #77 did not receive tirzepatide on 7/2/26. A progress note written by Nurse #6 on 7/2/26 documented medication unavailable, awaiting order. Nurse #6 was interviewed on 7/21/26 at 11:49 AM. Nurse #6 reported she attempted to administer the medication to Resident #77 on 7/2/26 and the tirzepatide was not available. Nurse #6 explained she called the on-call provider and received an order to move the administration day to Saturday and then reordered the medication from the pharmacy. A physician order dated 7/4/26 discontinued the order to administer tirzepatide 12.5 mg on Thursday and indicated tirzepatide 12.5 mg to be injected every Saturday.A pharmacy packing slip dated 7/4/26 indicated 2 pens with 4 doses of tirzepatide per pen was delivered on 7/4/26 at 8:16 PM. The signature on the receipt was illegible.The MAR revealed Resident #77 received tirzepatide 12.5 mg on Saturday 7/4/26 and Saturday 7/11/26. Resident #77 did not receive tirzepatide on Saturday 7/18/26. A progress note written by Nurse #7 documented waiting on pharmacy delivery.Attempts were made to contact Nurse #7 for interview and those attempts were unsuccessful.A phone interview was conducted with the Pharmacist on 7/21/26 at 9:46 AM. The Pharmacist indicated that some tirzepatide pens had multiple doses and some had one dose per pen. The Pharmacist reviewed the packing slips for 2/24/26, 3/10/26, 3/20/26, 4/2/26, 5/21/26, 6/12/26, and 7/4/26 and explained the doses of tirzepatide and number of pens that had been delivered. The Pharmacist explained the medication could be refilled early with an override from the facility, but he did not know if an override had been completed for Resident #77's tirzepatide.The medication refrigerator was observed on 7/21/26 at 2:00 PM with Nurse #8. There were no doses of tirzepatide for Resident #77. The refrigerator was in the locked medication room. The refrigerator did not lock. Nurse #8 explained that all nurses on the B-side of the building had a key to the medication room. Resident #77 was interviewed on 7/19/26 at 11:18 AM and she reported she had been missing doses of tirzepatide for months. Resident #77 explained she was told by nursing staff that the medications had not been delivered from the pharmacy, but she felt like it happened at least once per month, and the doses had not been replaced. Resident #77 said she did not recall all the specific dates she did not receive the medication other than yesterday, 7/18/26. Resident #77 described feeling nauseated and fatigued when she missed a dose and then received the full dose a week later, It's almost like I'm starting all over with the medication. Resident #77 described the day after tirzepatide as a day where she didn't feel like she could do much because of fatigue and nausea and reported skipping a dose made the nausea and fatigue more intense.The Unit Manager was interviewed on 7/21/26 at 2:09 PM. The Unit Manager explained that on 7/2/26 Resident #77 had 4 doses of tirzepatide delivered to the facility. The Unit Manager reported on 7/6/26 she counted the doses and found that instead of having 3 remaining doses (after administration of the medication on 7/4/26), Resident #77 had only 2 doses of the medication. The Unit Manager explained that a tirzepatide pen was missing from the refrigerator. The Unit Manager reported she suspected someone had taken the tirzepatide. Unit Manager reported she started a count sheet on 7/6/26 for the medication and when nursing staff administered the tirzepatide, they were to count the remaining doses. The Unit Manager reported on 7/18/26 when Nurse #7 went to administer the medication, there were no doses left for administration. The Unit Manager explained she called the pharmacy and determined that one dose of medication would be sent weekly and kept in a locked refrigerator in her office, and the administration date and time would be moved to day shift on Tuesday, so the medication would be handed to the nurse and she or the Director of Nursing (DON) could monitor the medication. The Unit Manager reported they attempted to determine which nurse was taking the medication, but they were unable to because there were too many nurses assigned to work with that medication cart. The Unit Manager reported Resident #77 was the only resident to receive tirzepatide in the facility.The DON was interviewed on 7/21/26 at 2:26 PM. The DON explained she had been in her position for 3 weeks and had no idea that Resident #77 was not receiving her prescribed tirzepatide until the Unit Manager told her on 7/6/26. The DON reported the facility suspected someone was taking the tirzepatide. The DON reported a refrigerator that locked had been ordered and the medication was to be kept in the Unit Manager's office and either she or the Unit Manager would provide the medication to the nurse for administration. The DON reported there was not a camera in the medication room to capture images of which nurse accessed the refrigerator and prior to this, there had been no process in place for tracking medications that were not narcotics. The DON reported she expected high value medications to be locked up and distributed by the Unit Manager during the day when the administration of the medication could be supervised.The facility Physician was interviewed by phone on 7/21/26 at 3:49 PM. The Physician reported he was not aware of the missing doses of tirzepatide for Resident #77. The Physician reported Resident #77 was not harmed by the missed medications. A phone interview was conducted with the Nurse Practitioner on 7/22/26 at 11:09 AM. The Nurse Practitioner explained she was not aware Resident #77 had not been receiving doses of tirzepatide and Resident #77 had not mentioned this to her during her visits with the resident. The Nurse Practitioner reported she did not believe Resident #77 was harmed by the missed tirzepatide doses. The Administrator was interviewed on 7/22/26 at 2:50 PM. The Administrator reported the medications were usually delivered by pharmacy at night and the receiving nurse was responsible for securing the medications, but there was no process in place for medications that were not narcotics. The Administrator reported because there was not a process in place for non-narcotic medications, someone felt they could take the tirzepatide. The Administrator reported the management team became aware of the missing medications when the Unit Manager discovered the tirzepatide pens were missing on 7/6/26. The Administrator reported the Unit Manager had attempted to discover who took the medication by interviewing the nurses who had access to the medication room during that weekend, but the Unit Manager was not able to identify anyone. The Administrator reported she expected a process to be put in place to secure high value medications and that no medications were taken by nursing staff.

Based on record review and interviews with resident and staff, the facility failed to report an allegation of misappropriation of property to the State Agency, Adult Protective Services and law enforcement for suspicion of diversion of a resident's medication for 1 of 3 residents reviewed for misappropriation of property (Resident #77).The findings included:Review of the facility Abuse Policy dated 1/23/20 indicated misappropriation of property included the theft of a resident's medication and the facility reported incidents or allegations to the State Agency with an initial report for occurrences of alleged or reasonably suspected crime against a resident, including misappropriation of resident property.Resident #77 was admitted to the facility on [DATE] with diagnoses including diabetes and sleep apnea. A physician order dated 7/4/26 indicated tirzepatide (a medication used for the treatment of elevated blood glucose levels, sleep apnea and weight management) 12.5 milligrams (mg) to be injected every Saturday.Resident #77 was interviewed on 7/19/26 at 11:18 AM and she reported she had been missing doses of tirzepatide for months. Resident #77 explained she was told by nursing staff that the medications had not been delivered from the pharmacy, but she felt like it happened at least once per month, and the doses had not been replaced. Resident #77 said she did not recall all the specific dates she did not receive the medication other than Saturday, 7/18/26.Review of the facility's initial and investigation reports revealed no report had been submitted for Resident #77 related to missing tirzepatide.The Unit Manager was interviewed on 7/21/26 at 2:09 PM. The Unit Manager reported on 7/6/26 she counted the doses of Resident #77's tirzepatide and found that a tirzepatide pen was missing from the medication refrigerator. The Unit Manager stated she suspected someone had taken the tirzepatide and reported this information to the Director of Nursing (DON). The Unit Manager reported they attempted to determine which nurse was taking the medication, but they were unable to because there were too many nurses assigned to work with that medication cart. The Unit Manager reported when the tirzepatide dose was missing on 7/18/26, she was certain a nurse was taking the medication. The Unit Manager reported Resident #77 was the only resident to receive tirzepatide in the facility. The DON was interviewed on 7/21/26 at 2:26 PM. The DON reported the facility suspected someone was taking the tirzepatide, but she and the Unit Manager were unable to identify any staff responsible for the missing medications. The DON explained when the tirzepatide dose for 7/18/26 was not available, they were certain a nurse was taking the medication. The Administrator was interviewed on 7/27/26 at 4:31 PM by phone. The Administrator reported when the tirzepatide was discovered as missing on 7/6/26 the facility was not investigating it as misappropriation and did not file a report with the State, notify Adult Protective Services or notify law enforcement because they did not think a crime had been committed. The Administrator reported the Unit Manager had attempted to discover who took the medication by interviewing the nurses who had access to the medication room during that weekend, but the Unit Manager was not able to identify anyone.

Based on observation, record review, and interviews with staff, resident, and the resident's Responsible Party, the facility failed to provide incontinence care when needed for 1 of 8 dependent residents reviewed for activities of daily living (ADL) (Resident #23).Findings included:Resident #23 was readmitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, congestive heart failure, and stroke.A physician order dated 4/2/25 specified to give furosemide (a diuretic medication used to remove excess fluid by increased urination) 40 milligrams by mouth twice daily.The annual Minimum Data Set (MDS) dated [DATE] documented that Resident #23 had moderate cognitive impairment and was fully dependent on staff for all ADL, including hygiene, dressing, transfers to and from her wheelchair, and bed mobility when turning side to side, or changing position in the bed or chair. Resident #23 was always incontinent of urine and stool, had an unstageable pressure ulcer (skin pressure injury with an undetermined depth and stage) and moisture-associated skin damage (inflammation and erosion of the skin caused by prolonged exposure to moisture from sources such as urine, stool, sweat, and wound exudate). The care plan dated 7/6/26 documented that Resident #23 had a pressure ulcer and incontinence associated dermatitis (reddened raw areas of skin to the groin caused by prolonged contact with urine or stool). Interventions included to provide prompt incontinence care, maintaining clean and dry skin, and turn and reposition the resident often to prevent further skin injury. The care plan documented that Resident #23 required a two person assist for bed mobility.Review of the Wound Care note dated 7/15/26 at 2:27 PM by the Wound Nurse Practitioner indicated that resident #75's left and right ischium and peri wound were denuded (skin rubbed off), erythematous (reddened), excoriated (scraped skin), fragile (easily torn), macerated (overly wet), and had non-blanchable (persistently red) dark red discoloration with induration (firm swelling). There was a moderate amount of serosanguinous drainage. The wounds were described as stable.On 7/19/26 at 10:35 AM, Resident #23 was observed asleep with the head of bed elevated to approximately 30 degrees. Resident #23 wore a silk nightcap and hospital gown. Her linens appeared clean, and no staff were observed providing care. There was no urine odor detected upon entry.On 7/19/26 at 11:20 AM, Resident #23 remained asleep with the head of bed near 30 degrees. Her gown, cap, blanket, and linen arrangement remained unchanged. No staff were observed providing care. There was no urine odor detected upon entry.On 7/19/26 at 1:30 PM, Resident #23 was observed in bed with the head of bed elevated at approximately 30 degrees. A urine odor was noted upon entering the room.During an observation and interview on 7/19/26 at 2:35 PM with Nursing Assistant (NA) #9, the NA was observed preparing to complete a full bed bath and linen change for Resident #23. NA #9 indicated that she was changing the bed linens due to a large amount of urinary incontinence. A strong urine odor was present. The hospital gown Resident #23 wore was wet and the fitted sheet under Resident #23 was wet and had a yellow-colored ring that extended out to the side of the mattress. NA #9 reported she first rounded on Resident #23 at approximately 9:00 AM and washed her hands and face after breakfast and provided incontinence care at that time. NA #9 stated Resident #23 required incontinence care at least every two hours and more often if drinking fluids. NA #9 stated she did not return to provide incontinence care after lunch trays were delivered and acknowledged she had not provided any care since the 9:00 AM round. NA #9 reported that she delivered the lunch tray to Resident #9 and had to return to the meal cart to deliver other residents' lunch trays. NA #9 stated she then had to pick the trays back up after lunch was over. When asked why she hadn't provided care before lunch, or after lunch, MA #9 replied she got busy with other residents and didn't make it back to Resident #23.On 7/19/26 at 3:30 PM during an interview with Resident #23's Responsible Party (RP), she reported that she arrived on 7/19/26 around 1:30 PM and observed Resident #23's gown and bed linens were wet with urine. The RP stated she used the call light and asked NA #9 who was assigned to Resident #23 and requested the NA provide incontinence care. She reported that NA #9 stated she was assigned to Resident #23 and was preparing to change all of the bed linens and provide a bed bath. The RP reported NA #9 left the room and returned after approximately 20 to 30 minutes with a stack of linens to provide care. The RP stated she frequently visited for 6 to 8 hours per day and had observed periods of four or more hours without care or repositioning. The RP stated she often found the resident wet and smelling of urine and expressed concern that staff were not checking the resident every couple of hours. The RP reported she had expressed her care concerns to the nursing leadership previously on multiple occasions but was unable to provide exact dates.Resident #23 was interviewed on 7/20/26 at 11:15 AM, immediately after wound care was provided, and reported that staff had not changed her or gotten her dressed for the day on 7/19/26 until well after lunch. Resident #23 reported it was an issue that her RP talked to the nursing leadership about. Resident #23 stated she had bathing products and clothing that were provided by her family and there were always clean linens for her to have so did not know why the staff ignored her. She reported that she asked to be changed on 7/19/26 when they brought her lunch tray in and NA #9 said she would be back to do it and she did not. Resident #23 could not recall who picked up her lunch tray or if she asked again to be changed and get dressed.Multiple attempts to conduct a telephone interview with Nurse #9 who was assigned to Resident #23 on 7/19/26 were unsuccessful.An observation of the Wound Nurse providing wound care to Resident #23 and interview were conducted on 7/20/26 at 10:30 AM. Resident #23 had non-blanchable maroon discoloration, redness, maceration, and excoriation to her peri area that extended from the mid-line of the right buttock to the inner groin folds, and upwards from her buttocks towards her left and right ischium (part of your pelvis that you sit on). Her inner thighs were reddened and excoriated. There were remnants of thick white barrier cream present in skin folds between her thigh and groin. The Wound Nurse indicated that the peri wounds were improving and she had notified the RP of the improvement. The Wound Nurse indicated that the right and left ischium wound and peri wounds could potentially be negatively impacted by any delay in providing incontinence care. The Wound Nurse indicated she provided wound treatments to Resident #75 every day, Monday through Friday. The Wound Nurse indicated she did not work on 7/19/26 and the agency nurse would have provided the prescribed daily wound care. The Wound Nurse reported that Resident #23's wounds looked better than the week prior.On 7/21/26 at 10:34 AM, the Assistant Director of Nursing (ADON) was interviewed and stated she was not aware that Resident #23 had not been provided with incontinence care for several hours on 7/19/26 from NA #9 or another staff member. The ADON stated that the care Resident #23 received on 7/19/26 did not follow her care plan and was not consistent with staff training. She stated the lack of incontinence care for Resident #23 from 9:00 AM to 2:30 PM was unacceptable. The ADON reported she met with Resident #23's RP approximately one month prior to address the concerns regarding nursing staff not providing incontinence care. The ADON stated NAs should make rounds on residents every 2 hours and provide incontinence care, if needed. The ADON reported that residents who were on medications that make them urinate or move their bowels more frequently should be checked more frequently. The ADON indicated she was disappointed that Resident #75 did not receive incontinence care for several hours and NA #9 was not trained to provide care in that manner. The ADON reported she planned to follow up with NA #9 on her next scheduled workday.On 7/20/26 at 1:50 PM, the Director of Nursing (DON) was interviewed. The DON stated she was not aware that NA #9 reported that she did not provide the care to Resident #23 between 9:00 AM and 2:00 PM on Sunday 7/19/26 because she needed to pass lunch trays and then pick them up afterward. The DON stated that NAs were expected to prioritize resident needs and that residents who were incontinent must be attended to promptly. She reported that staff should always change a resident's incontinence brief when the resident requests to prevent skin breakdown and to provide good customer service. The DON reported that what happened with Resident #23 on 7/19/26 was unacceptable.On 7/21/26 at 12:24 PM, the Administrator was interviewed and reported that staff were expected to round every two hours and notify the nurse if they were unable to provide required care. She stated there were no staffing or system issues that should have prevented timely incontinence care for Resident #23.

Based on record review, observations, and interviews with resident, pharmacist, physician, Nurse Practitioner, and staff, the facility failed to administer tirzepatide (a medication used for the treatment of elevated blood glucose levels, sleep apnea and weight management) as ordered for 1 of 7 residents reviewed for significant medication errors (Resident #77).The findings included:Resident #77 was admitted to the facility on [DATE] with diagnoses including diabetes and sleep apnea. A physician order dated 11/19/25 ordered tirzepatide (a once weekly injectable medication) 10 milligrams (mg) once weekly on Thursdays for diabetes.Resident #77 weighed 362 pounds on 9/5/25.Resident #77 weighed 384 pounds on 6/9/26. Lab results for Resident #77 included a hemoglobin A1C (labs used to measure average blood glucose results over the past 3 months) dated 9/11/25 of 6.8 (normal 4.0-6.0). Lab results dated 5/29/26 for Resident #77 included a hemoglobin A1C of 7.1. The Medication Administration Record (MAR) revealed Resident #77 received tirzepatide 10 mg on Thursday 2/26/26.A physician order dated 2/27/26 indicated Resident #77's tirzepatide dose increased from 10 mg to 12.5 mg to be injected every Thursday.The MAR revealed on Thursday 3/5/26, Resident #77 did not receive tirzepatide 12.5 mg. There was no progress note written by Nurse #2 to explain why she did not receive the medication.A phone interview with Nurse #2 was conducted on 7/21/26 at 3:08 PM. Nurse #2 reported she did not remember why Resident #77 did not receive the tirzepatide on 3/5/26. Nurse #2 reported if the medication was not given, the medication was not available. The MAR indicated Resident #77 received tirzepatide 12.5 mg on Thursday 3/12/26 and Thursday 3/19/26.The MAR indicated Resident #77 received tirzepatide 12.5 mg on Thursday 3/26/26.On Thursday 4/2/26 tirzepatide was documented as not given and the progress note written by Nurse #3 indicated waiting on pharmacy.A phone interview was conducted with Nurse #3 on 7/21/26 at 10:24 AM. Nurse #3 reported she was aware that a lot of the time the tirzepatide was not available for administration, and she did not know why. Nurse #3 was unable to report the specific dates.The MAR revealed Resident #77 received tirzepatide 12.5 mg on the following Thursdays: 4/9/26, 4/16/26, 4/23/26, 4/30/26, 5/7/26 and 5/14/26. On 5/21/26 there was a notation by Nurse #4 that the medication was not in stock and was not administered.Attempts were made to contact Nurse #4 for interview, and those attempts were unsuccessful.A physician order dated 5/22/26 indicated tirzepatide 12.5 mg to be injected on Friday 5/22/26.The MAR indicated Resident #77 was administered tirzepatide 12.5 mg on Friday 5/22/26.The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #77 to be cognitively intact. The assessment coded her to have received one injection during the look-back period, and she was taking hypoglycemic medications (medications used to control blood glucose levels).The MAR revealed on Thursday 5/28/26 and Thursday 6/4/26 Resident #77 received 12.5 mg of tirzepatide. On Thursday 6/11/26 tirzepatide 12.5 mg was not administered and Nurse #5 documented medication reorder in a progress note.A phone interview was conducted with Nurse #5 on 7/21/26 at 12:45 PM. Nurse #5 reported she remembered the tirzepatide was not available for Resident #77 on 6/11/26 and she called the pharmacy to request a refill. Nurse #5 did not know why the medication was not available. The MAR indicated Resident #77 received tirzepatide 12.5 mg on 6/18/26 and 6/25/26. Resident #77 did not receive tirzepatide on 7/2/26. A progress note written by Nurse #6 on 7/2/26 documented medication unavailable, awaiting order. Nurse #6 was interviewed on 7/21/26 at 11:49 AM. Nurse #6 reported she attempted to administer the medication to Resident #77 on 7/2/26 and the tirzepatide was not available. Nurse #6 explained she called the on-call provider and received an order to move the administration day to Saturday and then reordered the medication from the pharmacy. A physician order dated 7/4/26 discontinued the order to administer tirzepatide 12.5 mg on Thursday and indicated tirzepatide 12.5 mg to be injected every Saturday.The MAR revealed Resident #77 received tirzepatide 12.5 mg on Saturday 7/4/26 and Saturday 7/11/26. Resident #77 did not receive tirzepatide on Saturday 7/18/26. A progress note written by Nurse #7 documented waiting on pharmacy delivery.Attempts were made to contact Nurse #7 for interview and those attempts were unsuccessful.A phone interview was conducted with the Pharmacist on 7/21/26 at 9:46 AM. The Pharmacist indicated that some tirzepatide pens had multiple doses and some had one dose per pen. The Pharmacist reviewed the packing slips for 2/24/26, 3/10/26, 3/20/26, 4/2/26, 5/21/26, 6/12/26, and 7/4/26 and explained the doses of tirzepatide and number of pens that had been delivered. The Pharmacist explained the medication could be refilled early with an override from the facility, but he did not know if an override had been completed for Resident #77's tirzepatide.The medication refrigerator was observed on 7/21/26 at 2:00 PM with Nurse #8. There were no doses of tirzepatide for Resident #77.Resident #77 was interviewed on 7/19/26 at 11:18 AM and she reported she had been missing doses of tirzepatide for months. Resident #77 explained she was told by nursing staff that the medications had not been delivered from the pharmacy, but she felt like it happened at least once per month, and the doses had not been replaced. Resident #77 said she did not recall all the specific dates she did not receive the medication other than yesterday, 7/18/26. Resident #77 described feeling nauseated and fatigued when she missed a dose and then received the full dose a week later, It's almost like I'm starting all over with the medication. Resident #77 described the day after tirzepatide as a day where she didn't feel like she could do much because of fatigue and nausea and reported skipping a dose made the nausea and fatigue more intense.The DON was interviewed on 7/21/26 at 2:26 PM. The DON explained she had been in her position for 3 weeks and had no idea that Resident #77 was not receiving her prescribed tirzepatide until the Unit Manager told her on 7/6/26. The DON reported the facility suspected someone was taking the tirzepatide.The facility Physician was interviewed by phone on 7/21/26 at 3:49 PM. The Physician reported he was not aware of the missing doses of tirzepatide for Resident #77. The Physician reported Resident #77 was not harmed by the missed medications, her increase in Hemoglobin A1c and weight were not significant.A phone interview was conducted with the Nurse Practitioner on 7/22/26 at 11:09 AM. The Nurse Practitioner explained she was not aware Resident #77 had not been receiving doses of tirzepatide and Resident #77 had not mentioned this to her during her visits with the resident. The Nurse Practitioner reported she did not believe Resident #77 was harmed by the missed tirzepatide doses.

Based on observation, record review, and interviews with staff, the facility failed to ensure that the required privacy curtain was in place and maintained in a shared resident room for 1 of 6 residents reviewed for privacy (Resident #73).Findings included:Resident #73 was admitted to the facility on [DATE] with diagnoses including stroke, vascular dementia with agitation, speech and language deficits, and cognitive communication deficit. The annual MDS dated [DATE] documented severe cognitive impairment and total dependence on staff for all activities of daily living.On 7/19/26 at 11:09 AM, surveyor observed that the privacy curtain normally hung between Resident #73's bed and his roommate's bed was missing, with only approximately 12 inches of torn curtain remaining attached to the track. No curtain separated the two beds.On 7/19/26 at 11:13 AM, Nurse #17 reported she was unaware of a missing privacy curtain and indicated that a work order must be entered for the missing privacy curtain in Resident #73's room.On 7/20/26 at 9:30 AM the room still had no privacy curtain in place.On 7/21/26 at 9:43 AM, Nursing Assistant (NA) #6 reported that she was assigned to Resident #73 on 7/21/26 from 7:00 AM to 7:00 PM. She stated she was not aware that the privacy curtain was missing and noted that all shared rooms should have privacy curtains between the beds. NA #6 stated that if there was any issue with a privacy curtain (such as being broken, ripped, or soiled), she would report the concern to the nurse, who would then enter an emergency work order into the computer.On 7/21/26 at 10:34 AM, the Associate Director of Nursing (ADON) confirmed multiple nursing assistants (NA #7 and NA #8) had been assigned to Resident #73 over the dates the curtain had been missing and stated that staff were expected to notify the supervisor immediately when a privacy curtain was missing. The ADON reported a work order had been entered on 7/20/26 at 7:30 AM and that the curtain was not replaced until 7/21/26 at 10:30 AM.Attempts to contact NA #7 were unsuccessful.On 7/22/26 at 10:22 AM, during a telephone interview, NA #8 stated that the privacy curtain should be drawn before care is provided. NA #8 stated she did not report the missing curtain in resident #73's room to the nurse because she was unaware it was missing.On 7/20/26 at 7:10 AM, Nurse #14 stated she had been unaware the curtain was missing and explained that NA staff should have notified her so that she could enter a work order. Nurse #14 confirmed she submitted a work order on 7/20/26 at 7:30 AM.On 7/21/26 at 12:14 PM, the Housekeeping Director reported he had not been notified by housekeeping staff that the curtain was missing on 7/19/26 or 7/20/26. He explained he was informed only on 7/21/26 around 9:30 AM by nursing leadership and replaced the curtain by 10:30 AM.On 7/21/26 at 1:09 PM, the Maintenance Director reported that privacy curtain work orders were considered critical. He explained the first work order dated 7/20/26 at 7:30 AM had been closed prematurely because maintenance staff believed housekeeping had already installed the replacement curtain. A second work order later the same day was not recognized as a duplicate, contributing to the delay. The Maintenance Director stated this was a breakdown in communication between maintenance and housekeeping.On 7/21/26 at 12:24 PM, the Administrator stated she had been unaware that the curtain was missing and reported it was her expectation that every shared room maintain a functioning privacy curtain. She indicated the delay resulted from communication breakdown between departments.

Based on observations, record reviews, and interviews with staff and the Nurse Practitioner, the facility failed to apply a right hand C grip splint (a hand orthosis designed to support the wrist and fingers) as ordered by the physician for 1 of 1 residents (Resident #10) reviewed for contractures and range of motion (ROM).Findings included:Record review showed Resident #10 was admitted to the facility on [DATE] with diagnoses including stiffness of the right hand, hemiplegia (paralysis of one side of the body), and hemiparesis (severe weakness affecting one side of the body) following cerebrovascular disease affecting the dominant right side, muscle weakness, and dementia.Review of the care plan revealed the facility care planned Resident #10 as requiring assistance with activities of daily living (ADLs) due to chronic health conditions and cerebrovascular accident with hemiplegia (revision date 3/29/26). Interventions included the resident wearing a right hand C grip splint during nighttime hours for 8 hours or as tolerated, and referring to therapy as needed.Review of the Occupational Therapy Discharge summary dated [DATE] showed Resident #10 received Occupational Therapy services from 4/14/26 through 5/27/26. The long term goal was for Resident #10 to safely wear a C grip splint on the right hand, wrist, and fingers for up to 8 hours with minimal signs or symptoms of redness, swelling, discomfort, or pain. At discharge, the resident was able to tolerate the splint for 8 hours. Therapy discharged the resident due to achieving maximum potential. Discharge recommendations directed the resident to wear the C grip splint 8 hours daily or as tolerated.Review of orders dated 5/27/26 indicated: Patient to wear RIGHT C grip SPLINT during nighttime hours for 8 hours or as tolerated.Review of the Splint/Orthotic Wear and Care instructions from the Occupational Therapist dated 5/27/26 documented the splint was intended to prevent further contractures of the hands, wrists, and fingers. The resident was to wear the right C grip splint during nighttime hours for 8 hours daily or as tolerated. The document indicated that the nursing staff had been trained on splint application on 5/27/26. The nurse who signed the document that nursing staff was trained was not in the facility during the survey and was not interviewed.Review of the most recent comprehensive Minimum Data Set (MDS) assessment, a Significant Change dated 6/30/26, showed Resident #10 was severely cognitively impaired, did not exhibit behaviors or rejection of care, and had impairment in both upper and lower extremities. The resident required substantial to maximum assistance with most ADLs and was not on therapy services.Review of Resident #10's medication administration record (MAR), treatment administration record (TAR), and Point of Care (POC) documentation which were a part of the Electronic Medical Record (EMR) for June and July 2026 showed no documentation that staff applied or removed splints. Observations on 7/21/26 at 6:30 AM revealed Resident #10 in his wheelchair without splint.During an interview on 7/21/26 at 7:10 AM, Nurse #12 stated that she had been assigned to Resident #10 and worked the 7 PM to 7 AM shift. Nurse #12 stated she was not aware that Resident #10 had splint. Nurse #12 stated she had not applied splints and had not observed the resident wearing splint at night. After reviewing Resident #10's MAR and TAR in resident's EMR, she stated she did not see any splint orders. She was unsure where the resident's splints were located in his room.During an interview on 7/21/26 at 9:50 AM, the Rehabilitation Director stated Resident #10 had contractures in his right hand. He said the resident could move and open his right hand, and therapy recommended the C grip splint be applied at night. He stated the resident had been under Occupational Therapy services a few months prior because his splint was misplaced. The therapist verified proper fit, comfort, and skin integrity, and confirmed the resident tolerated the splint for 8 hours. After discharge, the Occupational Therapist educated nursing staff on hand exercises and splint application. Occupational Therapist provided the splint recommendations and orders to the unit nurse.In an interview on 7/21/26 at 9:50 AM, Unit Manager #1 stated the therapist entered a splint order on 5/27/26 into the EMR, but this order was not transcribed by the nurse into the MAR or TAR in the EMR. As a result, staff could not see the order or document application and removal of the splints. Unit Manager #1 stated she did not believe staff were applying the splints at night. Unit Manager #1 was unsure who was responsible for splint application. She indicated depending on the type of splint to be applied to the resident, Nurses and Nurse Aides were trained by therapy. Some splints could be easily applied by the Nurse Aides when trained and some required Nurses to apply the splint.An observation of the resident's room with Unit Manager #1 on 7/21/26 at 10:00 AM revealed Resident #10's splint was stored in the bottom drawer of the nightstand.During an interview on 7/21/26 at 1:55 PM, Nurse Practitioner #1 stated Resident #10 had right hand contractures and that the C grip splints would prevent the contractures from worsening. She stated the resident should wear the splints at night per therapy recommendations. She stated she should be notified if the resident refused the splints or if any concerns related to the splints or skin integrity arose.During an interview on 7/21/26 at 1:30 PM, the Director of Nursing (DON), stated that for any resident with splint ordered by therapy, the nurses must enter the splint order and transcribe it on to the MAR in resident's EMR. Once in the MAR, Nurses could see the order, apply the splint as directed, and document application or refusal. The DON stated if a resident repeatedly refused the splint application, had skin integrity concerns, or could not tolerate the recommended duration, then therapy and the DON should be notified.

Based on record review, and staff, Consultant Pharmacist and Medical Director interviews, the Consultant Pharmacist failed to identify and report medication transcription errors for 1 of 3 residents reviewed for medication review (Resident #6).The findings included: Resident #6 was admitted on [DATE] with diagnoses including dementia and benign prostatic hyperplasia (BPH, an enlarged prostate). Hospital discharge summary medication list dated 10/8/25 for Resident #6 included in part:- -Finasteride 5 milligrams (mg) tablet by mouth daily for BPH.- -Melatonin (sleep aid) 10 mg capsules, take 30 mg by mouth at bedtime. The facility's physician orders dated 10/8/25 included in part:- -Finasteride 5 mg by mouth two times a day for BPH.- -Melatonin 10 mg, 1 tablet by mouth at bedtime for supplement/prophylaxis.Further review of physician's orders dated 10/8/25 revealed there was no documentation for a verbal order changing the Finasteride or Melatonin doses from the hospital discharge summary medication list dated 10/8/25. Review of Resident #6's Medication Administration Record (MAR) for October indicated Resident #6 received:- -Finasteride 5 mg twice a day from 10/9/25 through 10/27/25. - - Melatonin 10 mg, 1 tablet at bedtime from 10/08/25 through 10/28/25. The Consultant Pharmacist Medication Regimen Review dated 10/19/2025, revealed that Resident #6's medication regimen contained no new irregularities or recommendations.During an interview with the Consultant Pharmacist on 10/29/25 at 1:05 PM she revealed that the process of reviewing a newly admitted resident's medications was to look at both the hospital discharge summary and the facility orders, and she would also look at the medical record history and physical if needed but doesn't think she noted that for Resident #6. She did not say that she had noted any discrepancies. The Consultant Pharmacist explained that she would have sent the DON an email for clarification if there had been a discrepancy. The Consultant Pharmacist further explained that she had done Resident #6's monthly Medication Regimen Review on 10/19/25 and she had not noticed any dose errors with Resident #6's Finasteride and Melatonin orders to have made any recommendations. The Consultant Pharmacist reviewed Resident #6's hospital discharge summary and facility physician orders during the interview and said that the facility had transcribed the Finasteride incorrectly. She said she thought the hospital had transcribed the melatonin dose incorrectly. The Consultant Pharmacist revealed that when discrepancies or recommendations were found with Medication Regimen Reviews that a Consultant Pharmacist Medication Regimen Review Report is sent electronically to the facility. An interview was conducted with the Director of Nursing (DON) on 10/29/25 at 9:30 AM. She explained that pharmacy usually sent a notification if there was a discrepancy about a medication order. The DON confirmed the facility had not received a notification related to a discrepancy for Resident #6. During an interview with the Medical Director on 10/29/25 at 10:15 AM, he reviewed the hospital discharge summary and facility medication orders with the surveyor. He revealed that 30 mg of Melatonin was a large dose and that he remembered having spoken with someone about this but could not remember who. The Medical Director stated he would expect the nursing staff and Consultant Pharmacist to cross-check admission medication orders for accuracy. The Administrator was interviewed on 10/29/25 at 1:20 PM. The Administrator explained that the Consultant Pharmacist would email or fax with any medication order discrepancies.

Based on record review, observation, and staff, Consultant Pharmacist and Medical Director interviews, the facility failed to have effective systems in place for ensuring medication orders for a new admission were transcribed accurately. Resident #6 was prescribed Finasteride (medication for enlarged prostate) 5 milligrams daily and instead was administered the Finasteride twice a day from 10/10/25 through 10/27/25. This occurred for 1 of 3 residents reviewed for unnecessary medications (Resident #6).The findings included: Resident #6 was admitted on [DATE] with diagnosis including benign prostatic hyperplasia (BPH, which is an enlarged prostate). There was no Minimum Data Set (MDS) assessment available.The hospital discharge summary medication list dated 10/8/25 for Resident #6 included Finasteride 5 milligrams (mg) one time a day by mouth.The facility's physician order dated 10/8/25 for Finasteride was to give 5 mg by mouth two times a day for BPH. Further review of the physician's orders dated 10/8/25 revealed there was no documentation of a verbal order changing the Finasteride dose from the hospital discharge summary medication list.Review of Resident #6's Medication Administration Record for October 2025 indicated Resident #6 received Finasteride 5 mg twice a day from 10/10/25-10/27/25. An interview with Unit Manager #1 occurred on 10/29/25 at 9:30 AM. Unit Manager #1 reviewed the hospital discharge medication list and facility's medication orders for Resident #6. She confirmed the dose of Finasteride was transcribed incorrectly. Unit Manager #1 further explained the cross-check process which included the other Unit Manager or the hall nurse reviewing admission medication transcription for accuracy. Unit Manager #1 also confirmed there was no documentation that the physician was notified to change the Finasteride order. During an interview with Nurse #1 on 10/29/25 at 10:00 AM, Nurse #1 stated she transcribed the medication orders for Resident #6 from the hospital Discharge summary dated [DATE]. During the interview an observation of the computer screen labeled medication audit for Resident #6 on 10/8/25 confirmed Nurse #1's name as the nurse that entered the order for Finasteride. Nurse #1 stated she didn't remember Resident #6's admission and after reviewing the hospital discharge medication list and the facility's physician orders, Nurse #1 stated that she made an error during the transcription. She also stated she would notify the nurse practitioner or physician if there was a discrepancy but doesn't remember doing this for Resident #6. In an interview with Unit Manager #2 on 10/29/25 at 11:15 AM, she stated there was a cross-check process for admission orders. Unit Manager #2 explained the admission nurse or the Unit Manager would transcribe the orders; the second check was the other Unit Manager and/or the nurse on the hall who also checked the accuracy of medication orders upon admission. She did not recall Resident #6's admission. The Consultant Pharmacist was interviewed on 10/29/25 at 1:32 PM. She stated the pharmacy had both the facility medication order and the hospital discharge summary order for Resident #6's Finasteride. The Consultant Pharmacist discussed the Finasteride order on 10/8/25 as 5mg once a day and that was what the medication card said. She further explained that the pharmacy sent 30 tablets and there were no refills. When discussing if an order didn't match a medication card, she stated that when a physician's medication order didn't match the card that staff should follow the order on the card. An interview with Nurse #2 was done on 10/29/25 at 1:40 PM, who was assigned to Resident #6 this day. Nurse #2 stated she didn't have Resident #6's Finasteride medication card, that she might have put it in the shred box. During the interview an observation of Resident #6's Medication Record on the computer screen showed the Finasteride scheduled for two times a day at 9:00 AM and 9:00 PM and that Finasteride had been re-ordered on 10/28/25. An observation of the medication card was unavailable. An interview was conducted with the Director of Nursing (DON) on 10/29/25 at 9:30 AM. The DON discussed that there was a checks and balance system in place to ensure accuracy for admission medication orders. She explained that there was a three-level system that included the hall nurse, the Unit Manager on the resident's hall, and the other Unit Manager checking admission orders for accuracy. The DON stated Resident #6's admission orders were transcribed incorrectly due to human error, and the cross-checks probably were not completed. She further explained that pharmacy usually sent an alert if there was a discrepancy and no alert was received. The DON also discussed the admission Audit Checklist process. This document included a review that admission orders entered into the medical record matched the hospital discharge summary. It also included that if the in-house physician changed the orders, a clarifying progress note would be present. The DON stated the Unit Manager then the Assistant Director of Nursing would review the audit check list for completion, and she would have received the completed audits. The DON could not provide the admission Audit Checklist for Resident #6. An interview with the Medical Director on 10/29/25 at 10:15 AM, revealed he was familiar with Resident #6. He reviewed the hospital discharge medication list and the facility medication orders dated 10/8/25. The Medical Director also stated he was unaware of the Finasteride having been transcribed incorrectly and that this would not have caused harm to Resident #6. The Medical Director stated he would expect the nursing staff and Consultant Pharmacist to cross-check admission medication orders for accuracy. The Administrator was interviewed on 10/29/25 at 1:20 PM. She revealed the process for transcribing new admission orders involved nurses entering orders from the hospital discharge summary into the medical record, then being checked by the Unit Manager, and signed by the Medical Director to ensure accuracy. The Administrator was made aware of the transcription error for Resident #6 regarding the Finasteride. The Administrator stated Resident #6's Finasteride order was a transcription error.

Based on observation, record review, and staff interviews, the facility failed to provide foot care treatment ordered by the Podiatrist for 1 of 3 residents reviewed for foot care (Resident #1).The findings included: Resident #1 was admitted to the facility 2/24/25 with diagnoses including stroke and feeding tube. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was severely cognitively impaired.A podiatry note dated 7/1/25 documented foot care provided to Resident #1. The note included that Resident #1 had a chronic problem with dry skin (xerosis) and treatment included exfoliation and moisturization to prevent skin breakdown, which could increase the potential for infection. The note included the order to use a moisturizing cream daily to both feet, avoiding the area between the toes. This treatment was to continue for 3 months. Review of physician orders for Resident #1 revealed no order had been written to apply moisturizing cream to Resident #1's feet daily. Review of the treatment record for Resident #1 revealed no order had been written to apply moisturizing cream daily to Resident #1's feet. Resident #1 was observed on 8/6/25 at 11:51 AM in bed. His feet were noted to be very dry, with thick and flakey dead skin noted. Nurse #1 was interviewed on 8/6/25 at 1:13 PM. Nurse #1 reported she was assigned to Resident #1 and did not know about the podiatrist order for moisturizing cream to be applied to his feet. Unit Manager (UM) #1 was interviewed on 8/7/25 at 1:58 PM. UM #1 reported that she had not seen the podiatrist note dated 7/1/25 ordering the moisturizing cream to his feet. UM #1 explained that consultant visit notes were typically put into her box for her to review, but the podiatry note dated 7/1/25 had gone directly to medical records to be scanned into the electronic document system. UM #1 reported the order for the moisturizing cream should have been entered as a treatment order.A phone interview was conducted with nursing assistant (NA) #1 on 8/6/25 at 9:06 PM. NA #1 reported she had been assigned to Resident #1 this afternoon (8/6/25) and had not applied lotion or moisturizing cream to his feet. NA #2 was interviewed by phone on 8/6/25 at 9:20 PM and she reported she had not applied lotion or moisturizing cream to Resident #1's feet. NA #2 reported she had provided care to Resident #1 before he was hospitalized in July 2025. An interview was conducted with NA #3 on 8/7/25 at 12:43 PM. NA #3 reported she had been assigned to Resident #1 for the past several days (8/5, 8/6, and 8/7/25). NA #3 reported she had not applied moisturizing cream to his feet after his bath. The Director of Nursing (DON) was interviewed on 8/7/25 at 2:54 PM. The DON reported she was not aware the podiatrist had ordered moisturizing cream for Resident #1's feet to be applied daily. The DON reported that all consultant notes should be reviewed for orders. The Administrator reported that he expected all consultant notes to be reviewed for orders and entered into the electronic document system.

Based on observation, record review, staff and physician interviews, the facility failed to enter hospital discharge orders for tube feedings and free water administration for 1 of 3 residents reviewed for tube feedings (Resident #1). The findings included: Resident #1 was admitted to the facility 2/24/25 with diagnoses including stroke and feeding tube. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was severely cognitively impaired. The MDS documented Resident #1 received tube feedings. An order dated 7/11/25 indicated for tube feedings (Nutren 2.0) to be administered by pump at 60 milliliters (ml) per hour for 22 hours and turned off from 1:00 PM to 3:00 PM daily. The order directed a total of 1320 ml to be administered. An order dated 7/11/25 revealed free water flushes of 300 milliliters (ml) to be administered 5 times per day. Resident #1 was transferred to the hospital on 7/31/25 and was readmitted to the facility 8/5/25 after hospitalization. Hospital discharge orders dated 8/5/25 specified that Resident #1 should return to his previous diet. Review of the medication administration record (MAR) revealed there were no orders for tube feeding or free water flushes. Resident #1 was observed on 8/6/25 at 11:51 AM in bed. Tube feeding Nutren was infusing by pump at 60 ml per hour. An interview was conducted with Nurse #2 on 8/6/25 at 1:18 PM. Nurse #2 explained she received report from the hospital for Resident #1 before he arrived to the facility. Nurse #2 reported the hospital instructed her to continue previous tube feeding orders, and she reported this to Nurse #1. When Resident #1 returned to the facility, Nurse #2 hung the Nutren tube feeding. Nurse #2 reported she was not assigned to Resident #1 and did not notice the orders for the tube feeding or free water flushes were not added to the medication administration record. Nurse #1 was interviewed on 8/6/25 at 1:13 PM. Nurse #1 reported she was assigned to Resident #1 on 8/5/25 when he returned from the hospital and she was told by Nurse #2, who received report from the hospital, to continue the same tube feeding as before. Nurse #1 explained she hung the Nutren at 60 ml per hour as before and gave him free water flushes as before, but she did not notice that the orders for the tube feeding had not been added to the medication administration record. Nurse #1 explained she had hung a replacement container of the tube feeding at 9:30 AM because the previous container was empty and had given him flushes of water after the medication administration but had not administered free water flushes this date. Nurse #1 reported the Unit Manager was responsible for entering hospital discharge orders into the electronic documentation system. The Unit Manager (UM) #1 was interviewed on 8/6/25 at 1:25 PM and she reported she had received the hospital discharge orders for Resident #1 and had entered the orders on 8/5/25. UM #1 reviewed the medication administration record and reported that she must have forgotten to add the tube feeding formula, the rate of administration, and the free water flushes to the orders. UM #1 explained she was going to review the orders that morning on 8/6/25 but did not have the opportunity. A phone interview was conducted with the Registered Dietician (RD) on 8/6/25 at 12:36 PM. The RD explained that Resident #1 was receiving continuous feeding by feeding tube and receiving 2640 calories per day, plus 1500 ml of free water flushes. The RD reported she did not receive a phone call from the facility requesting clarification of dietary orders after Resident #1 returned to the facility after hospitalization. A phone interview was conducted with Nurse #3 on 8/6/25 at 10:21 PM. Nurse #3 reported he was assigned to Resident #1 for the night shift 7:00 PM on 8/5/25 to 7:00 AM on 8/6/25. Nurse #3 explained the tube feeding was running at 60 ml per hour and he had allowed that to run all night. Nurse #3 reported he had not noticed there were no orders for the tube feeding nutrition or for the free water flushes, but he had given water after administering medications (amount unknown) and had given him 240 ml of water at bedtime and in the morning. Nurse #3 reported he did not document the administration of these water flushes, and he used his nursing judgment for the administration of the water flushes. The physician was interviewed on 8/7/25 at 11:05 AM and he reported that nursing staff should not use their nursing judgement for tube feeding water flushes, and the facility should have called him on 8/5/25 to receive tube feeding and free water flushes orders and to clarify the hospital orders. The Director of Nursing (DON) was interviewed on 8/7/25 at 2:54 PM. The DON reported the facility reviewed orders received the day before during the morning meeting and she did not know why UM #1 did not call to clarify the tube feeding and free water flushes orders with the physician. The DON reported the hospital discharge orders for Resident #1 dated 8/5/25 were not reviewed during the morning meeting on 8/6/25. The Administrator reported that he expected all hospital discharge orders to be clarified as needed and entered into the electronic document system.

Based on record review, observations, and staff, resident representative, and physician interviews, the facility failed to effectively supervise a resident with moderate cognitive impairment, repeated falls, and impulsive behaviors. Around 12:00 PM on 7/13/25 Resident #1 left the facility without staff's knowledge and ambulated approximately 0.6 miles from the facility in 90-degree heat with 60% humidity. Resident #1 was discovered sitting in a ditch on the side of the road approximately 0.6 miles from the facility. Two passersby stopped to help him and called Emergency Medical Services (EMS). In addition, Housekeeper #1 was on her lunch break and in a car when she happened to see him on the ground on the side of the road. Housekeeper #1 stopped to give Resident #1 assistance and stayed with Resident #1 until EMS arrived. Resident #1 was sent to the hospital for evaluation and treatment for low blood pressure, weakness, urinary tract infection, and pneumonia. There was a high likelihood for serious injury or death considering the resident's cognition, impulsivity and resulting medical conditions. This deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents.Immediate jeopardy began on Sunday, 7/13/25, when Resident #1 left the facility without staff's knowledge and walked 0.6 miles away from the facility. Immediate jeopardy was removed on 7/17/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and ensure monitoring systems put into place are effective.The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including chronic obstructive lung disease, Parkinson's disease, repeated falls, spinal stenosis (a narrowing of the spinal vertebra causing nerve pain and weakness), extrapyramidal symptoms (side effects from taking antipsychotics; involuntary muscle movements), schizophrenia, and anxiety disorder. Physician medication orders for Resident #1 were as follows:Gabapentin (an anti-seizure medication used for nerve pain) 400 milligrams (mg) three times per day ordered on 4/18/25. Haloperidol (an antipsychotic medication used for control of severe agitation and aggression) 10 mg three times per day ordered on 4/18/25.Clozapine (an atypical antipsychotic used to treat mental illness like schizophrenia) 100 mg 3 tablets twice per day and Clozapine 50 mg twice per day (for a total of 350 mg twice per day) ordered on 4/21/25. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS documented Resident #1 did not wander and had no behaviors. The MDS assessed Resident #1 to require partial assistance to walk 10 feet, and he was dependent on walking 50 feet or more. The MDS documented Resident #1 did not use ambulation devices. The MDS documented Resident #1 was taking antipsychotic medications, antianxiety medications, and medications for seizure disorder. The active care plans in effect on 7/13/25 were as follows: Fall potential due to impulsivity. The interventions included resident education to call for staff assistance, place common items within reach, and remind Resident #1 to use call bell; Behaviors related to the use of psychotropic medications. The goal stated Resident #1's behaviors would not cause him distress, and interventions included to monitor for behaviors, including elopement, delusions, hallucinations, aggression, or refusing care;Cognitive impairment and included the goal that Resident #1 would not have any complications due to cognitive impairment. Interventions for this care plan included observing for changes in cognition and reorient Resident #1 as needed;Antipsychotics use, with interventions to monitor for behaviors, monitor for adverse medication reactions, and provide psychiatric services; andLevel II PASRR (Pre-admission Screening and Resident Review, a screening tool used for residents with a serious mental condition to ensure the resident receives appropriate services). The care plan interventions included psychological/psychiatric interventions or consultation as ordered. A Physician Assistant (PA) note dated 7/3/25 documented an examination after an unwitnessed fall on 7/2/25 where Resident #1 reported he had gotten up too quickly and his legs got weak. The note documented generalized weakness, fatigue, leg weakness, and anxiety. Resident #1 was confused, with impaired insight, and oriented to person. The note documented a recommendation for Resident #1 to use a wheelchair for mobility due to weakness, and to continue fall precautions and neurological checks. A phone interview was conducted with Resident #1's Representative on 7/17/25 at 10:42 AM. The Representative reported Resident #1 had paranoia and had delusions with auditory hallucinations episodes in the past and on Saturday 7/12/25 Resident #1 called the Representative and told them that a resident at the facility wanted to fight him. The Representative reported Resident #1 did not seem to be upset or mention wanting to leave the facility. The Representative reported Resident #1 said he did not want to fight this other resident. The Representative reported he had not reported to the facility that Resident #1 had called him regarding the other resident wanting to fight him because Resident #1 did not seem to be upset or concerned. An interview was conducted with Nursing Assistant (NA) #1 on 7/16/25 at 4:04 PM. NA #1 reported she was assigned to Resident #1 on Sunday, 7/13/25, and he had appeared to be his normal self. NA #1 explained that Resident #1 was mostly independent with washing up, dressing, and toileting and rarely called for help. NA #1 reported she had seen Resident #1 sometime between breakfast and lunch, but did not recall the exact time, and reported he had not said anything to her about being fed up and did not seem to be upset at all. NA #1 reported that Resident #1 had a routine of sitting in the front lobby from just after breakfast until after lunch, when he would return to his room to rest before dinner. NA #1 reported Resident #1 had never showed any signs of exit-seeking. Nurse #2 was interviewed by phone on 7/17/25 at 9:06 AM. Nurse #2 reported she was assigned to Resident #1 on 7/13/25 and had administered his morning medications to him. Nurse #2 reported Resident #1 was just fine, no distress, no discomfort and he had approached her after breakfast for his morning medications. Nurse #2 reported Resident #1 did not act abnormally or mention that he was fed up. Nurse #2 explained that Resident #1 had a routine, and he would sit in the front lobby most of the day until after lunch and then return to his room to rest in the afternoon. Nurse #2 reported Resident #1 had not been exit-seeking or expressed any desire to leave. An interview was conducted by phone with Receptionist #1 on 7/16/25 at 1:41 PM. Receptionist #1 reported he worked weekends and some evenings, and he was familiar with Resident #1. Receptionist #1 reported on Sunday, 7/13/25 sometime before noon, Resident #1 had approached Receptionist #1 and asked him to open the front door so Resident #1 could sit outside on the front porch. Receptionist #1 explained he checked the elopement book (a book kept at the front entrance and at the nursing stations with pictures and demographics of residents at risk for elopement) and because Resident #1 was not in the elopement book, he unlocked the front door and allowed Resident #1 to exit the building and sit on the front porch. Receptionist #1 reported he did not notify a nurse that Resident #1 was outside, and he recalled several other times Resident #1 had requested to sit outside. Receptionist #1 explained that sometime after 12:00 PM, Housekeeper #1 came into the facility through the front door and notified him that Resident #1 was found on the side of the road. Receptionist #1 reported that Resident #1 did not act upset or agitated, and Receptionist #1 did not think anything was wrong with allowing Resident #1 to sit outside on the porch. An interview was conducted with Housekeeper #1 on 7/16/25 at 12:09 PM. Housekeeper #1 explained she clocked out for lunch at 12:00 PM on 7/13/25. Housekeeper #1 turned right out of the facility and right again onto the road that ran behind the facility. Housekeeper #1 reported that about one half a mile from the facility, she saw a man sitting in the ditch on the side of the road and recognized him as Resident #1. Housekeeper #1 described Resident #1 as wearing long pants, shoes, a short sleeve T-shirt, and he was sitting on the ground, sweating, and appeared to be shaking. Housekeeper #1 reported two bystanders were with Resident #1 and they reported they had called EMS. Housekeeper #1 reported Resident #1 had said he was fed up and left the facility but did not say anything more than that. Housekeeper #1 reported she stayed with Resident #1 until EMS arrived and then she returned to the facility, where she notified Receptionist #1 and the Nursing Supervisor (Nurse #1). A nursing note written by Nurse #1 dated 7/13/25 documented Resident #1 went to Receptionist #1 and requested to be let out to sit on the front porch. The Receptionist opened the door and Resident #1 went to the chairs on the front porch and seated himself. Receptionist #1 went back to his desk to attend to his job. Housekeeper #1 was coming back from lunch and stated she saw this resident sitting by the ditch in the grass. Housekeeper #1 reported she stayed with Resident #1 until EMS arrived, which was called bystanders. The note documented Resident #1's representative was notified Resident #1 was taken to the hospital for evaluation. Nurse #1 was interviewed on 7/16/25 at 3:11 PM. Nurse #1 reported she was the weekend supervisor, and she usually worked from 11:00 AM to 11:00 PM on Saturday and Sunday. Nurse #1 explained she had forgotten something in her car, and she saw Resident #1 outside on the front porch when she went out to her car. Nurse #1 reported Resident #1 did not appear upset. Nurse #1 was not certain what time she had gone to her car but recalled at 12:20 PM on 7/13/25 Receptionist #1 had reported to her that Resident #1 was discovered sitting in a ditch on the side of the road and EMS had been called. Nurse #1 reported she called the hospital to get a report on Resident #1, and called the police, the resident representative, the Administrator, the Director of Nursing (DON), and the on-call physician. The EMS report dated 7/13/25 at 12:02 PM documented a clinical impression of generalized weakness with behavioral/psychiatric episode. Vital signs for Resident #1 were as follows: Blood pressure 102/58 at 12:16 PM, 93/52 at 12:18 PM, and 93/54 at 12:19 PM (normal 120/80), pulse 77 at 12:16 PM, 133 at 12:18 PM, and 132 at 12:19 PM (normal 60-100). Temperature at 12:16 PM was 98.3 (normal 98.6). The report documented Resident #1 had left the facility after an altercation with another resident. Resident #1 reported weakness, and he was assisted to stand and transfer to the stretcher where he was transferred to the hospital emergency department for evaluation. Emergency Department records dated 7/13/25 at 12:49 PM documented Resident #1 was walking for 45 minutes when a bystander called for EMS. Resident #1 reported he left the facility because he thought another resident was going to beat him up. Resident #1 reported weakness and buttocks pain from walking and sitting on the ground. Resident #1 was assessed to be alert and oriented with a blood pressure of 81/64. The note documented that Resident #1 was fed up with the facility and wanted to take a long walk. Resident #1 reported feeling disoriented, but he was assessed to be alert and oriented to person, place, time, and situation. At 1:05 PM his temperature was 100.3 degrees, heart rate 114, respiration rate 30 (normal 12-20), and blood pressure 94/61. Blood work revealed his blood glucose was elevated at 170 (normal 70-120) and lactic acid (a by-product produced by the body after exercise; elevated levels can be attributed to infection and poor oxygenation) was elevated to 3.6 (normal 0.5-2.2). A chest x-ray showed possible pneumonia. The note concluded that Resident #1 had no signs of trauma, no neurological signs indicating a stroke and he was admitted to the hospital with altered mental status, elevated lactic acid level, acute kidney injury, pneumonia, and lightheadedness. Hospital records were reviewed and urinalysis with culture and sensitivity was collected on 7/13/25 and the results on 7/14/25 showed greater than 100,000 e. faecalis (a bacteria that causes a urinary tract infection). A nursing note dated 7/13/25 documented Resident #1 was admitted to the hospital on [DATE] and remained hospitalized on [DATE].An observation of the route from the facility to the place where Resident #1 was discovered in a ditch on the side of the road was conducted by car with Housekeeper #1 and the Administrator on 7/16/25 at 12:25 PM. Turning right from the parking lot, the road was two lanes with a 35 miles per hour speed limit. The road did not have a sidewalk, and there was an incline from the facility to the stop sign at the intersection of the road. Turning right at the stop sign, this road was also 2-lane with a speed limit of 35 miles per hour with several curves and a slight incline. There was no sidewalk on this road and houses were located back from the road. The distance from the facility to where Resident #1 was located was approximately 0.6 miles. While the observation of the route was taking place, the Maintenance Director measured the distance from the front sitting area on the porch to the road as 223 feet. The weather on Sunday, 7/13/25, was mostly clear with partial clouds, the temperature was 90 degrees Fahrenheit and humidity was 60% and no wind according to historic weather on timeanddate.com. According to the national weather service, a heat index of 90 degrees and 60% humidity would be equivalent to 100 degrees Fahrenheit. The Physician was interviewed on 7/17/25 at 10:05 AM by phone. The Physician reported Resident #1 had not mentioned wanting to leave the facility and had not had a history of attempting to leave the facility. The Physician reported that Resident #1 spent most of his time sitting in the lobby and he had seen him sitting on the front porch a few times. The Physician reported he did not believe Resident #1 was cognitively able to leave the facility alone and reported Resident #1 had a significant chance of being injured by walking in 90-degree heat and without supervision. The DON was interviewed on 7/17/25 at 1:50 PM and she reported that new admission residents were assessed for elopement risk, and then quarterly and as needed after. The DON explained that Resident #1 had been assessed as a low risk for elopement and had no exit seeking behaviors, and for him to walk away from the facility was out of his normal behavior. The DON reported she was not aware Resident #1 had told his family that another resident wanted to fight him. The DON reported a binder was kept at the front desk and at each of the nursing stations with a picture of each resident who was at risk of eloping, and staff were expected to check the binder before allowing any residents to exit the building unsupervised. The Administrator was interviewed on 7/17/25 at 10:55 AM and he reported he started as the facility administrator on 7/14/25 and the former administrator was notified by phone on 7/13/25 when Resident #1 was found on the road one-half mile from the facility. The Administrator was notified of immediate jeopardy on 7/17/25 at 12:25 PM. The facility implemented a credible allegation of immediate jeopardy removal on 7/18/25.Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 diagnoses included (in part); Spinal stenosis in lumber region, pulmonary fibrosis, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's Disease, and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 04/25/2025 indicated that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 10 (which indicated moderate cognitive impairment). Resident #1 was also assessed to be always understood and able to understand others. Further review of Resident #1's MDS assessment indicated Resident #1 had no short-term or long-term memory problems. Review of Section GG (functional status) of the MDS assessment indicated Resident #1 is independent with ambulation, functional cognition, and was coded with no use of functional devices (such as wheelchair, cane, and/or walker). Review of Resident #1's elopement risk assessment dated [DATE] indicated a low risk for elopement. On 07/13/2025, between 11:30 am - 12:00 pm, Resident #1 walked to the front receptionist desk and requested to sit on the front porch. Resident #1 was not an elopement risk per initial assessment; therefore, was not in the Elopement Book (Elopement Book is a binder that contains residents who are at risk for elopement). The receptionist opened the front door and allowed Resident #1 out to sit on the front porch. Resident #1 walked out of the facility without the use of a wheelchair to sit on the front porch. Historically, Resident #1 routinely sat on the front porch. The facility front porch is not enclosed. At the time of exit on 7/13/2025, Resident #1 had on sweatpants, a T-shirt, and enclosed shoes. The clothing was appropriate for the weather conditions at the time he exited the facility. A facility housekeeper, Housekeeper #1, observed Resident #1 sitting on the grass, about half a mile from the facility during her lunch break. Housekeeper #1 further reported there were a couple of bystanders with Resident #1 who had already called 911/Emergency Medical Services (EMS) at the time she arrived at the scene. Housekeeper #1 remained with Resident #1 until Emergency Medical Services (EMS) arrived to transport Resident #1 to the local hospital for further evaluation and treatment. Housekeeper #1 then drove back to the facility and informed the facility Registered Nurse (RN) Supervisor she observed Resident #1 sitting on the grass about half a mile away from the facility beside the road and that Resident #1 was transported to the local hospital for further evaluations. Resident #1 was admitted to the local hospital for further evaluation and treatment on 07/13/2025. Resident #1 hospital records indicate he was admitted to the hospital with primary diagnosis of hypotension. Resident #1 remained in Hospital as of 7/16/2025. Upon return Resident #1 will be reassessed as a re-admission to the center following the revised process outlined below. The weekend supervisor completed a headcount of all residents in the facility; all residents were accounted for as of 07/13/2025. The facility placed a sign on the front door on 7/14/2025 to alert family and visitors not to assist residents outside without checking with the receptionist first and in-serviced Receptionist #1 on 7/14/2025. The Governing body led by the Regional Clinical Director, facility Administrator and Director of Nursing in collaboration with the selected members of the facility Quality Assurance and Performance Improvement (QAPI) committee conducted the root cause analysis on 07/14/2025, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. The root cause analysis (RCA) identified that the alleged noncompliance resulted from the failure to reassess Resident #1 when noted to have change in his exit seeking behaviors on 7/13/2025. The RCA concluded that Resident #1's elopement resulted from not being assessed as an elopement risk. The Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 completed elopement assessments on all residents in the facility on 7/14/2025 to identify any resident at risk for elopement. All identified residents at risk for elopement were added to the Elopement book at each nurse's station and the front desk for easy identification. On 07/14/2025, the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 updated care plans to include elopement risk interventions to prevent any successful attempts at elopement for all residents identified to be at risk. The Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 reviewed and updated the Elopement books to include resident demographic information and resident pictures for easy identification. This was completed on 07/13/2025 & 07/14/2025. These binders are located at each nurses' station and at the front desk. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Effective 07/16/2025, all new residents will have an elopement risk assessment completed on admission, readmission, quarterly, and with any changes in exit-seeking behavior, by the licensed nurse on duty. Any resident identified to be at risk for elopement will have appropriate interventions in place and an updated care plan for elopement. The nurse on duty will update residents' information in the elopement binder to include demographic information and pictures. Effective 07/16/2025, the facility clinical team including the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 revised the process of reviewing all new admits/readmits in a daily clinical meeting. This includes provisions for reviewing elopement assessments to ensure they are completed and documented in electronic medical records, appropriate care plans are in place, and the elopement binders are updated. Any discrepancies identified will be corrected promptly. Findings of this systemic change are documented on the Daily Clinical Meeting Report Form located in the Daily Clinical Meeting Binder. The Regional Clinical Director in-serviced the DON/ADON on 7/13/2025 & and 7/14/2025 on how to direct the nursing staff upon any identification of exit-seeking behaviors. These steps will be implemented to include completing the Elopement Assessment, updating the Care Plan, and updating the information in the Elopement Risk Book at each nurse's station and front desk. 100% education of all current staff, including full-time, part-time, and as-needed nursing employees, will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1 and #2). The emphasis of this education includes, but is not limited to, the importance of completing elopement assessments on admission, readmission, quarterly, and upon changes in exit-seeking behaviors. Staff education also focuses on the importance of updating care plans for each resident determined to be at risk for elopement, maintaining updated elopement binders at each nurse station and the front desk, and ensuring residents listed in the elopement binder are not allowed to exit the facility independently. This education will be completed by 07/16/2025. Any staff members not educated on or by 07/16/2025 will not be allowed to work until they are educated. This education will be provided annually and will be added to the new hire orientation for all new employees effective 07/16/2025. Immediate Jeopardy Removal date: 07/17/2025 The validation of the credible allegation of immediate jeopardy removal was conducted on 7/18/25 by interviewing nursing assistants, nurses, administration, housekeepers, receptionists regarding elopement prevention, elopement assessments, monitoring residents for exit-seeking behaviors, updating the elopement binders, and care plans. Sampled residents' medical records were reviewed for updated elopement assessments and elopement care plans. Education was reviewed. The immediate jeopardy was removed on 7/17/25.

Based on record review and staff, Medical Director, Physician Assistant (PA), and mobile x-ray provider interviews, the facility failed to notify a medical provider when the results of an x-ray revealing an intertrochanteric fracture of the right femur (type of broken hip that occurs between the bumpy parts at the top of the thigh bone) were reported to the facility on 3/19/25. This resulted in the fracture not being reported to PA #1 until 3/20/25 which delayed Resident #85's transfer to the hospital for evaluation and treatment. Resident #85 was sent to the hospital for an evaluation on 3/20/25 and on 3/21/25 Resident #85 received open reduction and internal fixation (a procedure to realign and secure broken bones with metal fasteners) to the right femur. This occurred for 1 of 15 residents (Resident #85) reviewed for accidents. The findings included:Resident #85 was admitted to the facility on [DATE] with diagnoses which included vascular dementia and hemiplegia (condition of complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following a stroke affecting the left non dominate side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #85 was severely cognitively impaired and was dependent on staff for transfers. A review of the nursing progress note dated 3/17/25 at 10:00 PM, written by Nurse #8, revealed Resident #85 was found sitting on the floor with complaints of leg pain and had no new injury. A review of Physician Assistant (PA) #1's note dated 3/18/25 at 4:35 PM indicated PA #1 visited Resident #85 for acute visit due to a fall on 3/17/25. PA #1 indicated that Resident #85 reported pain in right hip and right femur during the evaluation and she ordered an x ray. On 3/18/25, the facility's Physician Assistant (PA #1) ordered x-ray of Resident #85's right lower extremity due to complaints of pain post fall . A review of the Radiology Report for Resident #85 indicated an examination occurred on 3/19/25 at 10:02 AM and the results were reported to the facility via the electronic medical record on 3/19/25 at 12:13 PM. The finding was an acute transverse non-displaced intertrochanteric fracture and mild osteopenia was noted.A review of progress note dated 3/20/25 at 7:13 AM which was authored by Unit Manager #1 indicated Nurse #9 received Resident #85's x-ray results and which indicated a right femur fracture. The nurse informed Resident #85 and the Responsible Party and noted PA #1 would assess Resident #85 that morning. A review of progress note dated 3/20/25 at 9:27 AM which was authored by Unit Manager #1 indicated she notified PA #1 that the result of the x-ray for Resident #85 was an acute transverse nondisplaced fracture of the femur and that PA #1 referred Resident #85 to orthopedic as soon as possible.A review of the progress note dated 3/20/25 at 11:45 AM authorized by the Assistant Director of Nursing indicated that PA #1 had given an order to send Resident #85 to the hospital and that the Responsible Party was notified by UM #1.Review of hospital progress notes revealed Resident #85 was admitted on [DATE] for evaluation of femur fracture. The note further revealed resident #85 sustained an intertrochanteric fracture of right femur. On 3/21/25 Resident #85 received open reduction and internal fixation (surgical procedure used to treat severe bone fractures) to the right femur. Resident #85 was discharged back to the facility on 3/25/25.An interview was conducted with Resident #85's Responsible Party on 6/17/25 at 1:58 PM. He indicated that he would have wanted Resident #85 to have been sent to the hospital on 3/19/25 when the positive X-ray results were sent to the facility. An interview was conducted on 6/18/25 at 3:20 PM with Unit Manager (UM) #1. She indicated that x-ray results were reported to the facility in real time via the Electronic Medical Record (EMR) and that all nurses have access to the report. However, she or a nursing supervisor are normally the nurses that review the results. She also indicated that the mobile x-ray provider may also send a fax and call the facility with any positive reports. UM #1 indicated that Resident #85's x-ray results from his fall on 3/17/25 were uploaded into the EMR on 3/19/25 at 12:14 PM and noted the finding of a right femur fracture. She indicated that she normally leaves her shift around 2:30 PM and that she did not see the x-ray result before she left on 3/19/25. UM #1 further revealed that there was not a nursing supervisor working that evening, so she reviewed the result on 3/20/25 around 7:15 AM. UM#1 indicated that she reported the x-ray results to PA #1 around 9:30 AM on 3/20/25. PA #1 initially ordered an orthopedic referral as soon as possible and was not sure why this was ordered instead of an order for hospitalization. UM#1 indicated that PA #1 later gave a telephone order to the ADON to send Resident #85 to the hospital and Resident #85 was sent out around 10:40 AM.An interview was conducted with Physician Assistant #1 on 6/19/25 at 10:38 AM. PA #1 indicated she became aware of Resident #85's fall when she came into the facility the morning of 3/18/25. PA #1 indicated she reviewed the provider's communication book and saw a note from Nurse #8 related to Resident #85's fall. The note indicated that Resident #85 had an unwitnessed fall, reported pain and requested to go the hospital. She further revealed that she reviewed the triage notes that referenced the on-call provider's interactions with Nurse #8 during the time of the fall. PA #1 indicated that she evaluated Resident #85, and he did not exhibit uncontrolled or high levels of pain but during the range of motion evaluation to the right knee and hip, Resident #85 verbalized pain. PA #1 indicated she did not feel hospitalization was needed at that time due to Resident#85 not having a visible sign of injury, limited pain and a hospitalization would have been very taxing for Resident #85 to endure. She also indicated she ordered an x-ray at that time and expected to receive the result within the next 24 hours. PA #1 indicated she had access to the facility EMR, but she did not receive an alert that the x-ray result showed a positive finding for a right femur fracture. PA #1 further revealed that the notification process was for the Unit Manger to contact her with any positive x-ray results. PA #1 also indicated if she had been made aware of Resident #85's x-ray result on 3/19/25 she would have sent him directly to the hospital that same day. On 6/20/25 at 2:53 PM an interview was conducted with the Medical Director. The Medical Director indicated he did not feel that Resident #85 had experienced any uncontrolled pain or negative outcome after his fall on 3/17/25 due to the delay of hospitalization, however he would have wanted Resident #85 sent to the hospital for evaluation on 3/19/25 once the results were received. He indicated that he felt the facility nursing staff should have received a phone call from the mobile x-ray provider when they became aware of Resident #85's positive finding for a right femur fracture. On 6/23/25 at 9:10 AM a telephone interview was conducted with the Director of Marketing for Mobile X-Ray provider who completed the x-ray for Resident #85 on 3/19/25. She indicated that the company had a change in systems and was not able to access documentation to determine if the mobile x-ray provider contacted the facility by phone with results of the x-ray. She further revealed that the process was for the results to be automatically uploaded into the Electronic Medical Record (EMR) and the staff have access to this information in real time. She further explained that a fax was also sent and if there was a positive report such as a femur fracture then the provider would contact the facility by phone. An interview was conducted on 6/26/25 03:01 PM with the Administrator. She indicated the process for the mobile x-ray provider to report x-ray results to the facility staff was for the mobile X-ray provider to load the results in the electronic medical record, fax the results and to call if there was a positive result. The Administrator indicated the facility did have access to Resident #85's x-ray results in the electronic medical as of 3/19/25 at 12:13 pm but the facility did not receive a fax or phone call from the mobile x-ray provider to alert the staff of a positive x-ray result. She further revealed she would have expected the nursing staff to have been aware of Residents #85's x-ray result the day the results were uploaded in the electronic medical record and for the nurse to have notified the physician of the results that day.

Based on record reviews, and staff, Physician Assistant (PA), and Medical Director interviews, the facility failed to identify a change in medical condition required medical evaluation and treatment. Resident #85 fell and complained of pain to his lower right extremity on 3/17/2025. Resident #85 was assessed by PA #1 on 3/18/25 and an x-ray of the right lower extremity was ordered. The x-ray was completed on 3/19/25 and the results of an intertrochanteric fracture of right femur (type of broken hip that occurs between the bumpy parts at the top of the thigh bone) were reported to the facility on 3/19/25 at 12:13 PM. A medical evaluation and treatment of the fracture was delayed due to the x-ray results not being reviewed by facility staff or communicated to PA #1 until 3/20/25. Resident #85 was sent to the hospital for an evaluation on 3/20/25 and on 3/21/25 Resident #85 received open reduction and internal fixation (a procedure to realign and secure broken bones with metal fasteners) to the right femur. Resident #85 was discharged back to the facility on 3/25/25. The deficient practice occurred for 1of 15 residents reviewed for accidents (Resident #85). The findings included:Resident #85 was admitted to the facility on [DATE] with diagnoses which included vascular dementia and hemiplegia (condition of complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following a stroke affecting the left non dominate side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #85 was severely cognitively impaired and was dependent on staff for transfers. Review of Resident #85's care plan created on 7/15/24 with a revision date of 3/17/25 revealed a focus area for at risk for falls and injury related to weakness, altered mobility status and history of falls. Interventions included providing frequent reminders/cues to request assistance or wait for assistance with ambulation and transfers. A review of nursing progress note dated 3/17/25 at 10:00 PM, written by Nurse #8, revealed Resident #85 was found sitting on the floor with complaints of leg pain and had no new injury. A review of the eCare Triage (process used in healthcare settings to prioritize patients' treatment electronically to help prevent unnecessary emergency department visits) Note dated 3/17/24 at 10:11 PM indicated Nurse #8 contacted the on-call Provider #1 to report Resident #85 had an unwitnessed fall. The note further indicated Resident #85 had no injury and reported leg pain but was able to bear weight. On-call Provider #1 informed Nurse #8 that the pain may be coming from the fall but does not sound like a fracture or a dislocation concern. On-call Provider #1 gave an order for Acetaminophen 325 milligram (mg) 2 tablets by mouth every 8 hours as needed for pain up to 3 days. On-call Provider #1 also instructed Nurse #8 to monitor and report any changes to the provider and to follow up with Resident #85's primary care physician.A review of Resident #85's physician orders revealed an order on 3/17/25 for acetaminophen 325 milligrams (mg) orally two tablets every 8 hours as need for pain management status post fall for 3 days. A review of the initial incident report completed on 3/17/25 , written by Nurse #8, revealed Resident #85 had an unwitnessed fall in his room on 3/17/25 at 10:00 PM. The report indicated Nurse #7 called for Nurse #8 when Resident #85 was found sitting on the floor beside the bed. Nurse #8 completed a head-to-toe assessment with no injury noted. The report further revealed Resident #85 was wearing no skid socks but did not have any footwear in use. Resident #85 was able to move all extremities with right leg pain reported. The incident report did not state how Resident #85 was transferred post fall. Nurse #8 contacted the provider and the Responsible Party. The provider gave Nurse #8 an order for acetaminophen 325 mg 2 tablets every 8 hours as needed for pain which was administered and effective.An interview was conducted with Nurse #8 on 6/18/25 at 5:52 PM. She indicated she was the assigned nurse for Resident #85 on 3/17/25 from 7:00 PM to 7:00 AM and that Nurse #7 called for her when Nurse #7 observed Resident #85 in his room sitting on the floor beside the bed. Nurse #8 indicated she observed Resident #85's bed was in the lowest position, call light was in reach, and he was wearing nonskid socks. Nurse #8 indicated upon interviewing Resident #85 he indicated that he got up unassisted while trying to turn off the room light when he fell. Resident #85 denied hitting his head but reported right leg pain. Nurse #8 indicated there were no visible signs of injury noted at the time. Nurse #8 indicated that she completed a head-to-toe assessment which included moving Resident #85's upper and lower extremities was completed without difficulty. Nurse #8 further revealed that she pressed on the right leg to try and detect any injury, but no injury or source of pain was found. Nurse #8 indicated that although Resident #85 reported right leg pain, upon her assessment she did not discover any signs of injury, so she and Nurse #7 assisted him up to standing position and helped him back to bed. Nurse #8 further revealed that he was bearing weight at the time of the transfer and did not report additional pain or discomfort. Nurse #8 indicated that she notified the responsible party and on-call Provider #1 of the fall. She indicated that she made the on-call Provider #1 aware of the fall, the report of right leg pain and that he was weight bearing at the time of transfer without pain. The on-call Provider #1 ordered acetaminophen 325 mg 2 tablets for pain which she administered to Resident #85 after she received the physician order and put a note in the facility provider's communication book for evaluation. Nurse #8 indicated that at approximately 6:00 AM Resident #85 reported pain in right leg and requested to go to the hospital. Nurse #8 contacted the on-call Provider #2 to make a provider aware of the change, and the provider gave order for ibuprofen but when Nurse #8 returned to Resident #85's room, he had fallen back asleep, so the medication was not administered. Nurse #8 made the on-call Provider #2 aware, and she indicated that because Resident #85 had fallen back asleep and not in significant discomfort the nurse was to allow him to rest and have the facility provider see him in person that morning for further evaluation but to contact the provider again if any changes occurred. A review of eCare Triage Note dated 3/18/25 at 6:19 AM indicated Nurse #8 contacted on-call Provider #2 to report Resident #85 had a fall earlier in the shift , received acetaminophen for pain and requested to be sent to the hospital for pain. The on-call Provider #2 inquired if Resident #85 was willing to try ibuprofen but when Nurse #8 checked on Resident #85 he had fallen asleep. On-call Provider #2 and Nurse #8 agreed that he was no longer in pain as he had fallen asleep. The on-call Provider #2 asked Nurse notify the provider if Resident #85 is in pain and to follow up with primary care physician.Multiple attempts were made to interview Nurse #7 who first observed Resident #85 sitting on floor in his room post fall on 3/17/25, but attempts were not successful. Multiple attempts were made to interview on-call Provider #1 but attempts were not successful. Multiple attempts were made to interview NA #6 who was assigned to Resident #85 on 3/17/25 during the 7:00 PM to 7:00 AM shift but attempts were not successful.An interview was conducted on 6/19/25 at 11:01 AM with Nurse #12 who was assigned to Resident #85 on 3/18/25 during the 7:00 AM to 7:00 PM shift. She indicated that Resident #85 was not in pain and showed no signs of change from his normal behavior during the shift.An interview was conducted on 6/19/25 at 12:17 PM with NA #7 who was assigned to Resident #85 on 3/18/25 from 7:00 AM to 7:00 PM. She indicated Resident #85 showed no changes from normal behavior and did not report pain during this shift.An interview was conducted with on-call Provider #2 on 6/19/25 at 12:52 PM. She indicated that she was contacted by Resident #85's nurse on 3/18/25 at 6:19 AM and was updated on the fall that had occurred earlier in the shift and that Resident #85 had reported pain and requested to go to the hospital. The on-call Provider #2 further revealed that during the consultation with the nurse she discussed adding ibuprofen for pain relief if acetaminophen was not managing the pain. Nurse #8 went back to offer the medication to Resident #85, but he had fallen back to sleep. The on-call Provider #2 indicated that due to Resident #85 falling back asleep and therefore not exhibiting unmanaged pain, she felt it was in the resident's best interest to allow him to sleep and have the nurse contact the facility provider to have Resident #85 evaluated in person. She also indicated that she instructed the nurse to call the on call back if there were any changes in Resident #85 status. A review of physician order dated 3/18/25 at 11:45 am indicated an order for x-ray right lower extremity complaints of pain post fall one time for right lower extremity x-ray. A review of Physician Assistant (PA) #1's note dated 3/18/25 at 4:35 PM indicated PA #1 visited Resident #85 for acute visit due to a fall on 3/17/25. PA #1 indicated that Resident #85 reported pain in right hip and right femur during the evaluation and she ordered an x ray. A review of physician order dated 3/18/25 at 6:30 PM indicated an order to x-ray right extremity. Please x-ray tibia-fibula, femur and hip one timely only for right lower extremity x-ray for 1 Day.A review of the administration progress note dated 3/18/25 at 10:05 PM indicated Nurse #8 administered acetaminophen 325 mg 2 tablets for pain. There was no level of pain documented. A review of Resident #85's March 2025 Medication Administration Record (MAR) revealed acetaminophen 325 mg 2 tablets for pain was administered on 3/18/25 at 10:05 PM by Nurse #8. Resident #85 was documented to have pain at level 4 and the medication was effective. The MAR did not indicate if this medication was administered on 3/17/25, 3/19/25, or 3/20/25.A review of the Radiology Report for Resident #85 indicated an examination occurred on 3/19/25 at 10:02 AM and the results were reported on 3/19/25 at 12:13 PM. The finding was an acute transverse non-displaced intertrochanteric fracture and mild osteopenia was noted. The result was reviewed by PA #1 on 3/20/25 at 1:50 PM.A review of progress notes dated 3/19/25 revealed a note authored by Nurse #8 that indicated she administered acetaminophen 325 mg 2 tablets for pain management at 7:27 PM and it was effective. There was no level of pain documented.On 6/19/25 at 9:31 AM a follow up interview was conducted with Nurse #8. She indicated that she did not recall what days she administered the acetaminophen or why the MAR was blank on 3/17/25 and 3/19/25 but if she administered the medication then she should have signed off that it was given. Nurse #8 further revealed that Resident #85's pain was controlled. A review of progress note dated 3/20/25 at 7:13 AM which was authored by Unit Manager #1 indicated Nurse #9 received Resident #85's x-ray results which indicated a right femur fracture. The nurse informed Resident #85 and the Responsible Party and noted PA #1 would assess Resident #85 that morning. A review of progress note dated 3/20/25 at 9:27 AM which was authored by Unit Manager #1 indicated she notified PA #1 that the result of the x-ray for Resident#85 was an acute transverse nondisplaced fracture of the femur and that PA #1 referred Resident #85 to orthopedic as soon as possible.A review of the progress note dated 3/20/25 at 11:45 AM authorized by the Assistant Director of Nursing indicated that PA #1 had given an order to send Resident #85 to the hospital and that the Responsible Party was notified by UM #1.Review of hospital progress notes revealed Resident #85 was admitted on [DATE] for evaluation of femur fracture. The note further revealed Resident #85 sustained an intertrochanteric fracture of right femur. On 3/21/25 Resident #85 received open reduction and internal fixation (surgical procedure used to treat severe bone fractures) to the right femur. Resident #85 was discharged back to the facility on 3/25/25.Review of orthopedic consult note from the hospital dated 3/21/25 revealed Resident #85 had a Right Intertrochanteric femur fracture.An interview was conducted on 6/18/25 at 3:20 PM with Unit Manager (UM) #1. She indicated that x-ray results were reported to the facility in real time via the Electronic Medical Record (EMR) and that all nurses have access to the report. However, she or a nursing supervisor were normally the nurses that reviewed the results. She also indicated that the mobile x-ray provider may also send a fax and call the facility with any positive reports. UM #1 indicated that Resident #85's x-ray results from his fall on 3/17/25 were uploaded into the EMR on 3/19/25 at 12:14 PM and noted the finding of a right femur fracture. She indicated that she normally leaves her shift around 2:30 PM and that she did not see the x-ray result before she left on 3/19/25. UM #1 further revealed that there was not a nursing supervisor working that evening, so she reviewed the result on 3/20/25 around 7:15 AM. UM#1 indicated that she reported the x-ray results to PA #1 around 9:30 AM on 3/20/25. PA #1 initially ordered an orthopedic referral as soon as possible and was not sure why this was ordered instead of an order for hospitalization. UM #1 indicated that PA #1 later gave a telephone order to the ADON to send Resident #85 to the hospital and Resident #85 was sent out around 10:40 AM.An interview was conducted with Physician Assistant #1 on 6/19/25 at 10:38 AM. PA #1 indicated she became aware of Resident #85's fall when she came into the facility the morning of 3/18/25. PA #1 indicated she reviewed the provider's communication book and saw a note from Nurse #8 related to Resident #85's fall. The note indicated that Resident #85 had an unwitnessed fall, reported pain and requested to go the hospital. She further revealed that she reviewed the triage notes that referenced the on-call provider's interactions with Nurse #8 during the time of the fall. PA #1 indicated that she evaluated Resident #85, and he did not exhibit uncontrolled or high levels of pain but during the range of motion evaluation to the right knee and hip, Resident #85 verbalized pain. PA #1 indicated she did not feel hospitalization was needed at that time due to Resident #85 not having a visible sign of injury, limited pain and a hospitalization would have been very taxing for Resident #85 to endure. She also indicated she ordered an x-ray at that time and expected to receive the result within the next 24 hours. PA #1 indicated she had access to the facility EMR, but she did not receive an alert that the x-ray results showed a positive finding for a right femur fracture. PA #1 further revealed that the notification process was for the Unit Manger to contact her with any positive x-ray results. PA #1 also indicated if she had been made aware of Resident #85's x-ray result on 3/19/25 she would have sent him directly to the hospital that same day. On 6/20/25 at 2:53 PM an interview was conducted with the Medical Director. The Medical Director indicated he did not feel that Resident #85 had experienced any uncontrolled pain or negative outcome after his fall on 3/17/25 due to the delay of hospitalization, however he would have wanted Resident #85 sent to the hospital for evaluation on 3/19/25 once the x-ray results were received. He indicated that he felt the facility nursing staff should have received a phone call from the mobile x-ray provider when they became aware of Resident#85's positive finding for a right femur fracture. On 6/23/25 at 9:10 AM a telephone interview was conducted with the Director of Marketing for Mobile X- Ray provider who completed the X-ray for Resident #85 on 3/19/25. She indicated that the company had a change in systems and was not able to access documentation to determine if the mobile x-ray provider contacted the facility by phone with results of the x-ray. She further revealed that the process was for the results to be automatically uploaded into the Electronic Medical Record (EMR) and the staff have access to this information in real time. She further explained that a fax is also sent and if there was a positive report such as a femur fracture then the provider would contact the facility by phone. Multiple attempts were made to interview the Orthopedic surgeon, but attempts were not successful. An interview was conducted on 6/26/25 03:01 PM with the Administrator. She indicated the process for the mobile x-ray provider to report x-ray results to the facility staff was for the mobile x-ray provider to load the results in the electronic medical record, fax the results and to call if there was a positive result. The Administrator indicated the facility did have access to Resident #85's x-ray results in the electronic medical as of 3/19/25 at 12:13 pm but the facility did not receive a fax or phone call from the mobile x-ray provider to alert the staff of a positive x-ray result. She further revealed she would have expected the nursing staff to have been aware of Residents #85's x-ray result the day the results were uploaded in the electronic medical record and for the nurse to have notified the physician of the results that day.

Based on record review, and resident, staff, and Nurse Practitioner (NP) interviews, the facility failed to provide safe transport for a resident (Resident #421) in a wheelchair when Nurse Aide (NA) #5 transported Resident #421 to the shower room in a wheelchair without footrests. Resident #421's feet got caught underneath the wheelchair and she fell forward out of the wheelchair and onto the floor. Resident #421 sustained an acute comminuted fracture (broken into pieces) of the right distal femur (thigh bone just above the knee) requiring hospitalization and surgery. This deficient practice occurred for 1 of 11 residents reviewed for accidents.The findings included:Resident #421 was admitted to the facility on [DATE] and discharged to the hospital on 3/24/25. Her admitting diagnoses included stage 4 chronic kidney disease, type 2 diabetes, diabetic neuropathy (nerve damage due to diabetes causing pain, numbness and/or weakness in the feet and hands), muscle weakness, abnormalities of gait and mobility, repeated falls, chronic pain syndrome, coronary artery disease (narrowing of arteries that supply blood to the heart), cerebrovascular accident (stroke), and epilepsy.The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #421 was cognitively intact, used a manual wheelchair and required supervision/touching assistance with wheeling 50 to 150 feet in the wheelchair.The care plan dated 2/12/25 indicated Resident #421 required assistance with activities of daily living due to chronic health conditions, weakness, poor balance and a history of falls. The interventions included 1-person assistance with transfers and the use of a manual wheelchair for mobility. An incident report dated 3/24/25 at 10:00 AM completed by Nurse #6 revealed NA #5 was transporting Resident #421 to the shower room in a wheelchair when her foot was caught under the wheelchair and she was thrown out of the wheelchair to the floor landing on her right side. Resident #421 was complaining of right leg pain and was assessed by Nurse #6 with no visible signs of injury. The NP was notified of the incident and ordered an x-ray. The report further noted that footrests were not being used when the incident occurred. An interview conducted on 6/17/25 at 1:38 PM with NA #5 revealed NA #9 was assigned to Resident #421 on 3/24/25. NA #5 was helping NA #9 with her assigned residents and transported Resident #421 in a wheelchair from her room to the shower room. NA #5 stated the wheelchair did not have footrests but Resident #421 was able to hold her feet up. She revealed while transporting Resident #421 in the wheelchair down the hall she suddenly dropped her feet to the floor, and they got caught underneath the wheelchair. She indicated Resident #421 fell forward out of the wheelchair to the floor landing on her right side. NA #5 stated several staff were in the hall and responded to help and stayed with Resident #421 while she went to notify Nurse #6. She stated Nurse #6 responded immediately and assessed Resident #421. NA #5 revealed Resident #421 was complaining of right leg pain but had no visible injuries or deformities in the leg. She stated Nurse #6 completed an assessment they used the mechanical lift to transfer Resident #421 into the wheelchair and then back into bed. NA #5 stated she did not see any footrests in Resident #421's room and since she was able to hold her feet up, she went ahead and transported her in the wheelchair without them. NA #5 further stated footrests should be used on a wheelchair when transporting a resident because it was a standard of safety.A phone interview conducted with Nurse #6 on 6/19/25 at 8:40 AM indicated she was Resident #421's assigned nurse on 3/24/25. Nurse #6 indicated at approximately 10:00 AM she was notified by NA #5 that Resident #421 fell out of her wheelchair in the hallway. She revealed NA #5 reported to her she was pushing Resident #421 to the shower room in a wheelchair without footrests and her feet got caught underneath the wheelchair and she fell forward out of the wheelchair onto the floor. Nurse #6 indicated when she responded Resident #421 was lying on her right side and reported right hip and leg pain. Nurse #6 revealed she assessed Resident #421 and there were no visible signs of injury. She indicated Resident #421 had no visible signs of injury and was transferred with a mechanical lift back into the wheelchair and brought back to her room. She stated Resident #421 was transferred with the lift back into bed and was resting comfortably. Nurse #6 revealed she notified NP #1 of the incident, and she gave an order for an x-ray of Resident #421's right hip and leg. Nurse #6 indicated she administered pain medication to Resident #421 that was ordered as needed and monitored her closely. She stated the x-ray was completed and the results indicated Resident #421 had a right femur fracture. She revealed NP #1 arrived at the facility, assessed Resident #421, reviewed the x-ray results, and gave the order to transfer Resident #421 to the ED for further evaluation. Nurse #6 stated she was unsure why NA #5 did not use footrests on the wheelchair, but they should have been used for safety. The radiology results report dated 3/24/25 at 1:38 PM indicated an x-ray obtained of Resident #421's right leg revealed an acute transverse (straight across) mildly comminuted fracture (broken into pieces) at the distal femur (thigh bone just above the knee). The NP note dated 3/24/25 at 5:00 PM indicated Resident #421 was seen due to a fall from the wheelchair and complaints of right hip and leg pain. Resident #421 was being transported to the shower room in a wheelchair without footrests and her feet got stuck under the wheelchair and she fell forward out of the wheelchair onto the floor. The NP noted the wheelchair footrests were observed in Resident #421's room on the floor behind the bed and education was provided to Resident #421 and nursing staff on the importance of using the footrests for safety. Resident #421 was assessed and noted with bilateral lower extremity edema (swelling), however this was her baseline due to stage 4 chronic kidney disease. Resident #421 was non-compliant with fluid restrictions, refused to proceed with outpatient dialysis treatments and discussion of hospice services were ongoing with the resident and her family. Further examination of Resident #421's right leg revealed no deformities or visible signs of injury however the x-ray results were reviewed and indicated an acute transverse (straight across) mildly comminuted fracture (broken into pieces) at the distal femur (thigh bone just above the knee). The NP ordered Resident #421 to be transported to the Emergency Department (ED) for further evaluation.A nurse's note dated 3/24/25 written by Nurse #6 indicated Resident #421's x-ray results revealed a right femur fracture and order was received from NP #1 to transfer Resident #421 to the ED. Resident #421 left the facility via emergency medical services and transported to the ED for further evaluation.A review of the hospital records dated 3/24/25 revealed Resident #421 was evaluated in the ED due to a fall from a wheelchair and initial x-rays obtained at the facility indicated a right distal femur fracture. An x-ray obtained in the ED confirmed the right distal femur fracture. Resident #421 had surgery to repair the fracture on 3/25/25 and was discharged from the hospital to a skilled nursing facility on 4/17/25.During a phone interview with NP #1 on 6/18/25 at 10:00 AM she revealed she was notified on 3/24/25 that Resident #421 had a fall from her wheelchair and was complaining of right hip and leg pain. She stated she ordered an x-ray of Resident #421's right hip and leg to be obtained at the facility. NP #1 revealed she did not recall the time, but she was notified the x-ray results were received and arrived at the facility to assess Resident #421 and review the x-ray results. NP #1 indicated Resident #421 was lying comfortably in bed and she completed an assessment. She revealed Resident #421 was noted with swelling to both of her legs but that was her baseline due to stage 4 chronic kidney disease, non-compliance with fluid restrictions and refusal to proceed with dialysis treatments. NP #1 stated Resident #421 had no visible deformities or injuries to her right leg however the x-ray results indicated a right femur fracture. NP #1 revealed she gave an order to transport Resident #421 to the ED for further evaluation. NP #1 indicated Resident #421 fell from the wheelchair due to footrests not being used and her feet were caught under the wheelchair. NP #1 indicated staff reported to her they were unable to find the footrests however she observed them on the floor in Resident #421's room behind the bed. NP #1 stated she educated Resident #421 and the nursing staff on the importance of using footrests on the wheelchair for safety. She revealed Resident #421 was transferred to the ED on 3/24/25 but did not return to the facility and she was unsure what treatment she received in the hospital or the outcome of her injury.A phone interview was conducted with Resident #421 on 6/24/25 at 10:58 AM. She stated she did not recall many details of the incident that occurred on 3/24/25 but that a staff member was transporting her in a wheelchair and she fell out of the wheelchair onto the floor. Resident #421 indicated she fractured her right leg and remained in the hospital for a while following surgery. Resident #421 revealed she was currently residing in another nursing facility receiving therapy services and continues to recover from the leg fracture.During a phone interview with the Former Administrator on 6/19/25 at 1:08 PM she stated her employment at the facility ended on 3/27/25 and her last day in building was 3/24/25. She indicated she did not recall the incident that occurred with Resident #421 however staff should have used footrests on the wheelchair for safety.

Based on observations, record reviews and staff interview the facility failed to maintain frozen foods at or below 0 degrees Fahrenheit and failed to sanitize a thermometer probe used to test internal temperatures of food. These practices had the potential to affect food served to residents. The findings included: 1. On 6/16/25 at 10:35 a.m., the walk-in freezer was observed with the Dietary Manager (DM). The observation of the walk-in freezer revealed the internal thermostat read 32 degrees Fahrenheit (F). The frozen food items stored in the walk-in freezer were soft to touch. Internal temperatures taken by the Dietary Manager revealed: - one sleeve of raw ground beef was 46 degrees F - one case of raw chicken thighs was 28 degrees F - one case of raw sausage patties was 31degrees F - one case of precooked diced turkey was 27degrees F - one case of meatballs was 29 degrees F - one case of fish squares was 27 degrees F - one case of hotdog franks was 37 degrees F The DM was interviewed and stated he first noticed the walk-in freezer was not working properly when he arrived at work this morning (6/16/25) and reported the problem to the facility's Maintenance Assistant at 7:15 a.m. The DM reported he would have to throw out all the food items. During an interview on 6/16/25 at 11:15 a.m., the Administrator revealed the DM made her aware of the walk-in freezer not functioning that morning (6/16/25) at approximately 10:45 a.m. During an interview on 6/16/25 at 11:30 a.m., the facility Maintenance Assistant revealed the DM first made him aware the walk-in freezer was not maintaining proper temperatures on the morning of 6/16/25 at 10:58 a.m. 2. On 6/18/25 at 12:25 p.m. an observation of the lunch meal tray line was made. During the tray line observation, [NAME] #1 used a soiled hand towel from a food preparation table to wipe the thermometer's probe and proceeded to insert the probe into food items to check the internal temperatures. [NAME] #1 was interviewed and stated he had not worked at the facility long and indicated he did not receive any training by the Dietary Manager. The Dietary Manager revealed Dietary [NAME] #1 was rehired and began working at the facility on 6/9/25 and he (the DM) had provided orientation training but did not document it.

Based on record review, observations, and staff interviews, the facility failed to date and label insulin (Medication Cart #3 and Medication Cart #5) and failed to discard an opened out of date insulin injection pen (Medication Cart #3). The deficient practice were found in 2 of 3 medications carts reviewed for medication storage (Medication Cart #3 and Medication Cart #5). Findings included: a. An observation of Medication Cart #3 on 6/19/2025 at 4:45 pm revealed one glargine insulin injection pen that was open and dated and had not been labeled with the resident's name. Medication Aide #2 was interviewed during the medication cart observation on 6/19/2025 at 4:45 pm and stated she did not know why the glargine insulin injection pen was not dated and she was not sure how long it had been open in the cart. b. During an observation of Medication Cart #5 on 6/19/2025 at 3:38 pm a degludec insulin pen was not dated when opened. Nurse #2 was interviewed during the observation of Medication Cart #5 on 6/19/2025 at 3:38 pm and she stated she did not know why the degludec insulin pen was not dated. Nurse #2 stated when she opens a new insulin pen, she dated the label but someone else must have opened that insulin pen and she had not noticed it was not dated and had not used that insulin pen on any residents. c. The manufacturer's directions for insulin lispro pen stated it should be discarded 28 days after opening. Medication cart #3 was observed o 6/19/2025 at 4:45 pm and an insulin lispro injection pen was opened and was dated 5/15/2025. Medication Aide #2 was interviewed during the observation of Medication Cart #3 and she stated she did not know how long lispro insulin could be used after it was opened. She stated she thought the insulin lispro should be discarded after 30 days and she did not realize it was dated 5/15/2025. The Director of Nursing (DON) was interviewed by phone on 6/20/2025 at 9:28 am and she stated the insulin injection pens on medication cart #3 and medication cart #5 should have been labeled with the resident's name along with the date it was opened when placed in the medication cart. The DON also stated the lispro insulin injection pen that was opened and dated 5/15/2025 should have been discarded within 30 days of the date it was opened by the manufacturer's instructions. The DON stated the lispro insulin should have been sent back to the pharmacy after 30 days. During an interview by phone with the Administrator on 6/20/2025 at 8:35 am she stated the nurses and medication aides should have properly labeled and dated the medications when they are placed in the medication cart.

Based on record review, observations, and staff interviews, the facility failed to maintain effective pest control in 2 of 13 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for environmental concerns. Ants were observed in room [ROOM NUMBER] and room [ROOM NUMBER]. Findings included:The facility's extermination invoices were reviewed for the previous 6 months:On 12/11/2024 the facility received an extermination treatment for cockroaches and rodents.On 1/28/2025 the facility received extermination treatment for cockroaches and rodents and no pest were found in the facility during the visit.a. room [ROOM NUMBER] was observed on 6/17/2025 at 3:02 pm and ants were on the resident's bedside table and on the floor around her bedside table and bed. There were 5 ants on the floor and 3 ants on the top of the resident's bedside table that were reddish, brown in color. There was no open food or debris on the bedside table or the floor. During the observations the Responsible Party was present and stated they had killed several ants in the resident's room in the past few months and notified staff of the ants, but did not know what staff they told about the ants. On 6/18/2025 at 1:01 pm Nurse #2 stated she had not seen ants in room [ROOM NUMBER] until 6/17/2025 when the observation was made of room [ROOM NUMBER] and she was asked to observe the ants. Nurse #2 stated she made the Maintenance Director aware of the ants on 6/17/2025.Nurse Aide #4 was interviewed on 6/18/2025 at 1:08 pm and she stated she had seen several small, brown ants in room [ROOM NUMBER] several times, but she does not remember who she told. b. On 6/18/2025 at 8:33 am 3 ants were observed in room [ROOM NUMBER] crawling on the enteral feeding syringe that was in an open plastic bag which was on top of the bedside table and 2 ants on the towel that was on top of the bedside table. The tip of the enteral feeding tube was filled with clear liquid. Nurse #5, who was present in the room, stated they had been having problems with ants in the resident's rooms, and she had let the Maintenance Director know about the ants before today. During an interview with Nurse #5 on 6/18/20254 at 12:58 pm she stated she had seen ants in room [ROOM NUMBER] before today and they were on the beside table and the enteral feeding syringe that was in a plastic bag located on the top of the beside table. Nurse #5 stated she notified maintenance of the ants, disposed of the ants on the feeding syringe and the bedside table, and replaced the enteral feeding tube on the bedside table.An observation of room [ROOM NUMBER] was conducted 6/18/2025 at 6:02 pm and ants were observed crawling on the bedside table and on an enteral feeding syringe on the bedside table which was inside a plastic bag. During an interview with Nurse #5 on 6/18/2025 at 6:09 pm she stated she did not know what to do about the ants, but she would replace the enteral feeding syringe with a new syringe. Nurse #5 stated she had already notified the Maintenance Director about the ants before today and this morning when the observation was made of the ants on the bedside table and on the enteral feeding syringe that was in a plastic bag on top of the bedside table. During an interview with the Housekeeping Director on 6/19/2025 at 9:20 am she stated she had seen ants in the residents' rooms and the Maintenance Director was made aware and they had an exterminator treat the facility a week ago.The Maintenance Director was interviewed on 6/19/2025 at 9:23 am and he stated the facility was exterminated a week ago for pests and he does rounds to check for pests. An interview was conducted with the Director of Nursing on 6/19/2024 at 10:20 am and she stated she was not aware of ants being in room [ROOM NUMBER] or room [ROOM NUMBER] but the nursing staff should report any pests to the Nurse or Unit Manager so a work order can be sent to the Maintenance Director.During an interview with the Administrator on 6/19/2024 at 1:59 pm she stated the facility had been exterminated for other pests besides ants in the past two weeks but had not been exterminated for ants because no one had reported the ants to her. The Administrator stated the nursing, housekeeping, and maintenance staff should have notified her about the ants in room [ROOM NUMBER] and room [ROOM NUMBER] so that the extermination would remove the ants.

Based on record review, and staff and physician interviews, the facility failed to protect Resident # 2's right to be free from resident-to-resident abuse for 1 of 6 residents reviewed for abuse. On 12/7/2024, Resident #1 who had a history of aggression and anger outbursts; and received as needed antipsychotic medications, required a net bed (bed with mesh tent over hospital bed to prevent a person from getting out of bed) and a sitter while hospitalized , wandered into Resident #2's room and pulled Resident #2 from his bed while Resident #2 was asleep. Resident #1 struck Resident #2 in the throat and upper body with his foot and his fist. Both Resident #1 and Resident #2 were sent to the hospital for further evaluation on 12/7/2024. The resident-to-resident abuse had a high likelihood of resulting in serious physical and psychosocial harm. A reasonable person expects to be protected from physical abuse in their home and would suffer trauma such as feelings of fear, anxiety, and intimidation. The findings included: Hospital admission history and physical dated 10/2/2024 stated Resident #1 had been brought to the emergency department due to aggressive behavior displayed at a group home shortly after admission. Resident #1 became hostile towards staff and pulled a television off the wall. Telepsychiatry note dated 12/2/2024 while Resident #1 was in the hospital, revealed he was oriented only to self, displayed no behavioral concerns and was tolerating an increased dose of Seroquel without oversedation. The note further revealed Resident #1 had a nurse and/or sitter in the room and there were no psychiatric contraindications to placement. Hospital progress note dated 12/3/2024 stated Resident #1 was brought to the emergency department on 10/2/24 due to complaints of aggressive behavior and confusion. Resident #1 did have on and off anger outbursts and needed the net bed off and on. Resident #1 was receiving as needed (PRN) intramuscular (IM) Zyprexa (antipsychotic medication). The progress note further stated Resident #1 remained in the net bed which was opened with sitter present. Review of hospital progress note dated 12/4/2024 stated Resident #1 must remain out of restraints and the net bed for 48 hours prior to placement. The note indicated Resident #1 wanted to stay in the net bed despite it being discontinued. Hospital discharge summary dated 12/6/2024 included: - Resident #1's admission to the hospital on 10/2/2024 was due to complaints of aggressive behavior and confusion - Psychiatry had been consulted to evaluate and assist with Resident #1's behavioral disturbance - Psychotropic medications had been adjusted by psychiatry: Seroquel 100 milligrams (mg) twice daily (BID); Zyprexa for anxiety as needed (PRN) Resident #1 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF) and progressive dementia with behavioral disturbance. The admission/readmission nursing collection tool written by the interim Director of Nursing dated 12/6/2024 at 2:15 PM revealed Resident #1 was ambulatory and wandering in and out of other residents' room beginning at arrival to the facility. There was no intervention documented for Resident #1's wandering or potentially aggressive behaviors. Resident #1 was [AGE] years of age, 70 inches in height and weighed 121 pounds (lbs.). Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident with left hemiparesis (paralysis on one side of the body), anxiety, and major depression. The annual Minimum Data Set (MDS) assessment dated [DATE], stated Resident #2 was severely cognitively impaired. The MDS revealed Resident #2 did not display physical or verbal behaviors toward others and had no rejection of care. Resident #2 was dependent on staff for all activities of daily living (ADL) and had upper and lower extremity impairments. Resident # 2 was [AGE] years of age, was 70 inches in height and weighed 129.2 lbs. The review of nurse progress note written by Nurse #1 dated 12/7/24 stated Resident #2 had been attacked by Resident #1 and had been pulled from bed to floor by arm, bumping his head. Resident #2 had complained of head, arm, back, throat, and leg pain. Nurse #1 called the facility Administrator who advised Nurse #1 to send both Resident #2 and Resident #1 out for evaluation. Nurse #1 called the facility provider and contacted Resident #2's emergency contact to notify of incident and transfer to hospital. The police department responded, and Resident #2 was transported to the hospital by Emergency Medical Services (EMS.) Interview with Nurse #1 on 1/7/25 at 9:24 AM revealed she recalled getting to her shift around 11:00 PM on 12/6/24. She stated she observed Resident #1 walking toward the room they originally had him in upon admission. She believed the facility moved Resident #1's room due to his original roommate having a tracheostomy (a surgical hole in the windpipe that helps with breathing). She stated the facility was nervous due to Resident #1 wandering around his roommate and fear he would touch his roommate's tracheostomy equipment. Resident #1 was moved to a 4-person room. She stated Resident #1 wandered all night in several resident rooms. Nurse #1 revealed due to his wandering she had Resident #1 sit with her at the nursing station. The resident watched a little of a movie she had on an i-pad. When Resident #1 started to fall asleep, she took Resident #1 to his room to sleep. She stated he did not sleep long because she recalled being approached by nursing assistant (NA) #2 and asked where the other nurse could be located. NA #2 reported her resident (Resident #1) was dragging Nurse #1's resident (Resident #2) out of his bed. The nursing assistants she recalled notifying her were NA #1 and NA #2. Nurse #1 stated when she got to Resident #2's room he was lying on the floor like a pretzel and screaming. Resident #2 had his night gown around his upper torso and his brief was still in the bed. Resident #2 kept screaming why did Resident #1 do that to him. She stated one of the NAs went to locate the other nurse but could not locate her. While in Resident #2's room, Resident #1 was standing against the wall with his hands in his pockets, but he looked as if he was going to aggress towards Resident #2 again. She and the NAs could not get Resident #1 from Resident #2's room although staff were trying to redirect him out of the room. She further revealed Resident #1 stated it was his bedroom, and his bed and that's why he attacked Resident #2. Nurse #1 explained due to it being difficult to redirect Resident #1 she had NA #1 and NA #2 stay with Resident #1 while Nurse #1 took Resident #2 to the nursing station where the other nurse was located. She recalled the police showing up shortly after. She recalled Resident #2 having a reddened area to his neck and Resident #2 stating his head hurt, his back hurt and she believed he also mentioned his leg. Nurse #1 indicated she contacted the Administrator and the Interim Director of Nursing. She indicated after the incident she became aware that Resident #1 had tendencies to be aggressive and had an aggressive episode at his last placement. She was unaware of any interventions put into place for Resident #1's potentially aggressive behaviors. Interview with NA #1 on 1/7/25 at 7:30 PM revealed she recalled Resident #1 was in the process of a room change upon her arrival to the facility 12/6/24. She indicated her shift was from 7:00 PM to 7:00 AM. The only report she recalled being provided about Resident #1 was that he was a new admit, he walked and might have been incontinent. She was unsure of why Resident #1 was being moved but stated he was being moved to a 4-person room. NA #1 stated as the shift went on it got harder and harder to redirect Resident #1. Resident #1 would wander in and out of other resident rooms and NAs had to continuously tell Resident #1 that it was not his room. She stated other residents in the facility started to complain about Resident #1 standing in their doorways or entering their rooms, so she notified Nurse #1. She stated she was told by Nurse #1 to redirect Resident #1 to get him familiar with his room. NA #1 recalled when she would take Resident #1 to his room, he would continue to state that it was not his house. NA #1 stated after getting a resident a snack she observed Resident #1 standing over Resident #2 yelling at Resident #1 to get out of his room. She told Resident #1 that he was not in the right room. NA #1 stated before she could get all of her words out, Resident #1 grabbed Resident #2 by his contracted arm and with one hand tossed Resident #2 onto the floor from his lowered bed. NA#1 stated it happened quickly; she screamed. She stated once Resident #2 was on the floor, Resident #1 punched and stomped on his neck and chest area. NA #1 described Resident #2 as not being able to protect himself. She further revealed the incident happened so quickly; Resident #2 didn't have time to realize what was going on. Resident #2 asked out loud, why is he doing this to me. Referring to Resident #1. NA #1 revealed she had to push Resident #1 back from Resident #2 to get between them. NA #1 stated she had to stay between Resident #1 and Resident #2 because Resident #1 was continuously trying to get to Resident #2. NA #1 stated she asked if Resident #1 was ok and called out for help. Resident #2 had a red area to his throat and stated his neck hurt. She stated NA #2 came to assist and went to get the nurse. She recalled Nurse #1 stayed with NA #1 and the other Nurse was assisting with getting Resident #1 out of Resident #2's room. She stated after they got Resident #1 out of the room, he opened the door and re-entered the room. Resident #1 continued to state Resident #2 was sleeping in his bed and with his wife. NA#1 described the situation as a street fight. An interview was conducted with NA #2 on 1/7/25 at 8:20 PM. NA#2 indicated she was assigned the rehabilitation hall 12/6/24 and NA #1 was assigned to Resident #1's hall. She recalled hearing NA #1 yell out for help. When she arrived at Resident #2's room, NA #1 looked in shock. NA #2 indicated as soon as she got to the door of Resident #2's room, she observed Resident #1 grab Resident #2 by his arm and his leg and drag Resident #2 from his lowered bed to the floor. Resident #1 stomped on Resident #2's upper body with his foot while he was on the floor. She stated Resident #1 was angry and moved quickly. NA #2 described Resident #2 as a resident who could not defend himself against Resident #1's attack. Resident #1 kept saying it was his room. NA #2 stated she called for a nurse while she and NA #1 got in-between Resident #1 and Resident #2. NA #2 stated she had to grab Resident #1 by his arm to help get him away from Resident #2. Nurse #1 arrived first then Nurse #2. She recalled Nurse #1 trying to get Resident #1 from Resident #2's room. She stated after Resident #1 was removed from Resident #2's room he re-entered the room and demanded Resident #2 get out of what he believed was his bed. Interview with Nurse #2 on 1/7/24 at 9:53 AM revealed she recalled meeting Resident #1 as he was walking down the hall 12/6/24. Her assigned shift on 12/6/24 was 11:00 PM to 7:00 AM. Nurse #2 stated she had gotten in report that there was a new admission who was confused and wanted to go home. She did not recall getting the report that Resident #1 had a history of aggression. She assumed it was Resident #1 due to him looking lost. Nurse #2 recalled introducing herself and told Resident #1 she would walk him to his room. He was assigned to a room with 3 other residents. She stated on the way to Resident #1's room she recalled a couple of residents stating Resident #1 had walked into their rooms. Nurse #2 reoriented Resident #1 to his room, but she recalled being approached later by an NA (not known) and asked if Resident #2 was hers. Before she could answer the NA, Nurse #1 stated the NA revealed Resident #1 was hurting Resident #2. Nurse #2 stated 2 NAs (NA #1 and NA #2) had already separated Resident #1 and Resident #2. She further recalled Resident #2 being on the floor and Resident #1 having already been removed from the room. Nurse progress note dated 12/7/2024 at 7:54 AM written by an unknown nurse stated NA #1 notified Nurse #2 that Resident #1 pulled Resident #2 out of his bed to the floor then stomped on him. Nurse# 2 called Emergency Services, medical provider and Resident #1's representative. Review of the initial allegation report dated 12/7/24 revealed an allegation of abuse. The details of the report stated Resident #1 pulled Resident #2 from his bed while he was asleep. Resident #1 began striking Resident #2 in the throat. Resident #1 attacked Resident #2 for no reason. Resident #1 and Resident #2 were both separated. The police had to be called to the facility as staff could not get Resident #1's behavior under control. A head-to-toe assessment was completed, and no injuries were noted to Resident #2. Both residents were sent to the hospital for additional assessments. Resident #1 was removed from the facility with law enforcement assistance. The initial report was completed by the Administrator. Review of emergency department note dated 12/7/2024 stated the first provider evaluation of Resident #2 was completed at 6:34 AM. Resident #2 underwent computed tomography (CT) of his head, pelvis, chest, spine and abdomen. All CT scans were negative and showed no injuries or acute changes. Resident #2 was discharged back to the facility 12/7/2024. The emergency department note further indicated Resident #2's psychiatric status was cooperative, and he had normal judgment. Review of Resident #1's emergency department note dated 12/7/24 revealed a chief complaint of aggressive behaviors. The history of present Illness stated Resident #1 was an [AGE] year-old male, who presented to the emergency department for evaluation of aggressive behaviors. He was brought by EMS for wandering into another patients' room and pulling him out of bed. Patient states he thought that the other resident was in his bed. Resident #1 did not fall and had no injuries. An interview was conducted on 1/7/25 at 3:17 PM with the Nurse Liaison. She revealed all the nursing liaisons had access to referrals. She stated the case manager for the hospital would do a referral in which a bedside visit would be conducted. During the bedside visit the resident was assessed for medical readiness. The Nurse Liaison indicated she was assigned to the facility to assess referrals for potential admissions. She stated she discusses the referral with the Admissions Director who also had access to the potential referrals medical chart. She would verbally tell the facility what she observed while at bedside. The Nurse Liaison stated she would ask the hospital if restraints could be removed for 48-hour prior to admission. The hospital would not remove the restraints unless the resident was stable. The Nurse Liaison indicated she assessed Resident #1 as stable for admission to the facility because he did not have a restraint or a sitter for 48 hours and was not being chemically restrained. Interview with the Admissions Director on 1/6/24 at 2:47 PM revealed the admission process was once a resident's referral was uploaded, she would ask about behaviors, wounds, medical equipment needed, etc. The nurse liaison would conduct a bedside visit with the potential admission. If a resident had restraints the nurse liaison would inquire when the restraints would be discontinued because the facility did not admit residents who required restraints. Residents could be admitted to the facility if they were not displaying the behavior they were admitted to the hospital for and had to be without a sitter or restraint for 48 hours prior to admission. The Admissions Director indicated she was not clinical, so nurses did review the information provided by the hospital as well. She indicated that prior to Resident #1's admission she recalled discussing his admission with his guardian and was further aware of the resident having aggressive behaviors. She indicated she recalled the hospital documentation indicated Resident #1 was aggressive with staff and not residents. The Admissions Director could not recall who conducted Resident #1's bedside visit. Interview with the former interim Director of Nursing (no longer employed) via telephone on 1/6/25 at 3:45 PM revealed it was the responsibility of the nurse to complete admission assessment. Within the first 24 hours an interim care plan should be developed. She stated sometimes the discharge summary was not available upon a resident's admission and was unable to be used in developing the admission assessment. She could not recall if Resident #1's discharge summary was available for review upon his admission. The interim Director of Nursing stated she documented Resident #1 was wandering in other residents' rooms upon admission because she was approached by nursing and NAs. She further stated nursing staff had indicated Resident #1 was difficult to redirect. She stated she knew nothing about the resident prior to admission due to having several admissions in a couple of days. She indicated she did not recall implementing interventions due to his wandering. Nursing staff were aware they needed to redirect residents who wandered, provide them with activity, and in the instance, they became aggressive implement a one on one. She recalled being contacted by phone that Resident #1 had gone into Resident #2's room, grabbed Resident #2 by his contracted arm, pulled him out of bed and beat him. Resident #2 was sent to the hospital to be assessed for injuries. Interview with The Administrator on 1/7/25 at 2:12 PM revealed potential admissions were initially screened by nurse liaisons. The nurse liaison would look at the resident's physical condition and if the resident was being watched by a sitter. She stated if the resident had a sitter in place they would communicate that to the facilities Admission Director. Prior to admission a resident would need to be without a sitter or a restraint for 24 to 48 hours. She further revealed nursing should review a resident's record prior to admission. The Admissions Director should have access to the same information and would bring the information to the facility to review for the potential admission. The baseline care plan was put into place by the admitting nurse. The Administrator stated she was not aware Resident #1 was displaying wandering behaviors upon admission until after the incident occurred. She stated she expected the nursing staff to let her know Resident #1 was wandering so she could make a determination and included the DON for interventions. She stated interventions could be put into place such as one on one. The admission/readmission form included the interim plan of care. The admission/readmission form in the electronic medical record (PCC) form did not identify a place for behaviors. It only populated interim plan of care areas of side of effects of antianxiety, antipsychotic and antidepressant medications. The Administrator stated she believed the breakdown in communication was between the Nurse Liaison to the Admissions Director. Once the information was passed by the nurse liaison they were hands off. She stated the facility depended on the nurse liaison's expertise and that they were getting good information from the hospital. Interview with the Regional Consultant on 1/7/25 at 4:00 PM revealed the in-house admission nurse should review the discharge summary for potential behaviors and review the residents' medications. She stated Resident #1 had been cleared by psychiatry in the hospital and he was admitted to the facility. She stated when a resident began wandering in the facility, staff would have been expected to redirect the resident and to reorient him to the facility. She stated Resident #1's room was moved shortly after his admission due to his wandering. Interview with the Physician on 1/8/25 at 2:26 PM revealed it was his expectation that the facility reviews a resident discharge summary when available prior to potentially admitting a resident to the facility. As far as screening a resident prior to admission he was unaware of the process. He further stated he expected he could trust the discharge summary and the hospital discharge team when they indicated a resident was stable. The Administrator was notified of Immediate Jeopardy on 1/8/25 at 12:31 PM. The facility implemented the following Corrective Action Plan with a completion date of 12/12/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Facility failed to protect resident #2 from abuse after admitting resident #1 on 12/06/2024. On 12/7/24 at 5:30AM, Resident #1 wandered into Resident #2's room, who was a severely cognitively impaired resident and had impaired movement of both upper and lower extremities, while Resident #2 was asleep, and pulled him from his bed to the floor. Resident #1 physically attacked Resident #2 after he was pulled out of bed by his left arm (contracted) to the floor. Resident #1 stomped on Resident #2's upper body close to his neck and punched Resident #2 repeatedly. The 2 Residents (Resident #1 and Resident #2) were separated by 2 Nursing Assistants. Resident #2 was observed to have redness to his neck. Resident #1 stated he fought Resident #2 because he though Resident #2 was in his bed. Resident #2, who was receiving an anti-coagulant, complained of pain in his head, arm, back, throat, and leg pain. Nurse #1 notified the administrator and medical provider immediately. Resident #2 was sent to the hospital for evaluation. A computed tomography scan (CT) scan and chest x-ray revealed no injury. He was discharged back the facility on 12/7/24 with no new orders. Resident #1 was sent out immediately to the hospital for an evaluation. Resident # 1 was admitted to the hospital for eval and remains in psychiatric care. Resident #2 received a trauma screen assessment following the incident on 12/10/24 by Social Work staff. The 12/10/24 trauma screen indicated he was not fearful, in good spirits and not affected by the trauma. The trauma screen assessment recognizes Trauma Informed Care and acknowledges that residents who are trauma survivors may experience emotional, physical, and/or psychological difficulties that should be addressed immediately upon admission and throughout their stay in the Center. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk for deficient practice. The last seven days of progress notes of all residents as of 12/10/24 were reviewed for dementia behaviors including aggression, wandering, yelling, delusions, hallucinations, paranoia to ensure interventions are in place including psychiatric services as appropriate on 12/10/24 by the Administrator. All residents identified are receiving effective interventions and services from psych services as indicated. Current resident MD notes, incident accidents reports for behaviors or any resident to resident incidents were reviewed in the last 14 days for order of psychiatric consult, and referrals made if appropriate. This was completed 12/10/24 by the Director of Nursing and the Unit manager. All identified residents from review are currently being seen as indicated by psych services. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Resident #1 has not resided at the facility since the incident on 12/7/2024. Administrator, Director of Nursing, and/or the Unit Manager ensured training to all staff in all departments utilizing online learning education modules on dementia care to include wandering and managing aggressive behaviors. This education includes examples of dementia, wandering and aggressive behaviors and ways to prevent and manage these behaviors. This was completed 12/11/24. Including agency staff. All staff in all departments were educated by Administrator or designee that when a resident exhibits aggressive behavior, they will stay with them to provide one-on-one supervision and immediately notify a supervisor. This was completed 12/11/24. The Administrator or Director of Nursing will make the decision how long the resident will continue to receive one on one based on investigation. Any staff who did not receive the education by the compliance date was removed from the schedule until completed; this will be completed by the Director of Nursing. All new staff will receive education during the orientation process prior to floor training. All agency staff will be educated prior to beginning their first shift. This will be completed by the Director of Nursing or designee to ensure education is completed. Social Work staff are responsible for the initiation of psychiatric services when a consultation is placed. Administrator provided training to current social work staff to ensure psychiatric services referral are initiated following dementia behaviors including aggression. This was completed 12/11/24. The Administrator provided training to all current Social Work staff on 12/11/24 to ensure they will notify Medical Provider and Administrator when a resident or responsible party refuses psychiatric services. The Administrator provided education to all current Medical Providers on 12/11/24 that they will discuss on a case-by-case basis with the Administrator if services for psychiatry can be managed by the Medical Provider in house or if involuntary commitment is needed to provide psychiatric services. This is for resident or responsible parties who refuse psychiatry services. Director of Nursing will educate all staff on abuse and neglect related to what abuse is, the types of abuse to include resident to resident abuse and reporting. This was completed by 12/11/24. All new staff will receive education during the orientation process prior to floor training. All agency staff will be educated prior to beginning their first shift. This will be monitored by the Director of Nursing to ensure completion of education. All Nurses are responsible for notifying Medical Providers of each instance of change in condition which includes dementia behaviors and aggression. This practice is a current process as of 12/11/2024. In reviewing a resident for potential admission, the facility Admission staff reviews their history and physical and current hospital documentation including diagnosis and medication management. This process is currently in place as of 12/11/2024. Any potential admissions identified prior to admission with behaviors will be reviewed prior to admission by nursing to ensure interventions needed for potential behaviors and staff in-serviced on interventions as needed. After reviewing potential admission if resident behaviors identified are outside facility capabilities to manage admissions can deny admission of potential resident. Administrator or designee educated social work staff on 12/11/24 that when admitting a resident that has behaviors such as delusions/paranoia they will interview potential resident responsible party for information regarding current triggers and history of behaviors. This information will be communicated to the Director of Nursing. The Administrator educated The Director of Nursing on 12/11/24 that nursing will initiate interventions as appropriate at time of admission based on resident history related to aggressive behaviors and residents with signs of or history of wondering. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; On 12/11/24 the Quality Assurance committee to include Director of Nursing, Assistant Director of Nursing, Director of Admissions, Unit Coordinator, Maintenance Director, Medical Records, Director of Social Work, Activities Director, Business Office Manager, Human Resources, Administrator, Assistant Administrator, Director of Rehabilitation Services, Medical Director met and initiated the following monitoring plan. Director of Nursing and/or Unit Managers will review current resident and new admissions progress notes for dementia behaviors including aggression and ensure interventions are in place on resident baseline care plan daily Monday- Friday x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Monday audits will include the prior Friday, Saturday and Sunday. Director of Nursing or designee will audit physician progress notes and ensure that any psychiatric referrals have been consented and sent to psychiatric services Monday- Friday x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Monday audits will include the prior Friday, Saturday and Sunday. The Activity Director or designee will monitor Resident # 2 for changes in activity participation and will notify administrator of any changes for psychiatric intervention. This will occur 5 x weekly x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Social Worker or designee will complete psychosocial visits on Resident #2 for changes in current psychosocial state such as depression and/or anxiety 3x weekly x 8 weeks, then weekly x 4 weeks. Any changes will be reported to the administrator for psychiatric intervention. The Quality Assurance Performance Improvement committee will review all monitoring tools monthly for 3 months and make any necessary changes as needed immediately. Date of Compliance: 12/12/2024 The Corrective Action Plan was validated on 01/09/25 and concluded the facility had implemented an acceptable Corrective Action Plan on 12/12/24. Interviews with nursing staff revealed the facility had provided education and training on abuse, neglect and exploitation, handling combative residents/ resistant to care and how to deescalate and provide care to aggressive residents. Review of new admissions after 12/12/24 revealed the facility screened potential new admissions to include behaviors and potential interventions. The audits conducted starting on 12/11/24 revealed audits continued weekly through the validation date. The corrective action plan was reviewed with the Quality Assurance committee. The compliance date of 12/12/24 for the corrective action plan was validated. Immediate Jeopardy was removed on 12/12/24.

Based on record review, observations, and Nurse Practitioner and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #9). Nursing Assistant (NA) #2 rolled Resident #9 away from her during incontinence care, and Resident #9 fell out of bed. Resident #9 sustained a fractured left femur (long bone of the upper leg) and required surgical repair on 8/28/24. The findings included: Resident #9 was admitted to the facility 9/29/2017 with diagnoses including diabetes and lung disease. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #9 to be severely cognitively impaired and she required extensive assistance of 1 person for bed mobility and toileting. An incident report written by Nurse #3 dated 8/26/24 documented a witnessed fall of Resident #9 from her bed to the floor during the provision of incontinence care. The report documented the nurse entered Resident #9's room and noted Resident #9 was on the right side of her bed between the bed and the window and was lying on her left side holding her head up. NA #2 was in the room with Resident #9 and reported she was providing bedtime incontinence care and Resident #9 rolled out of bed. The incident report noted that no injuries were noted, Resident #9 denied hitting her head, and Resident #9 reported her leg hurt and she wanted pain medication. The incident report documented the facility physician was notified of the fall on 8/26/24 at 9:00 PM and the resident responsible party was notified at 9:15 PM. A phone interview was conducted with NA #2 on 8/28/24 at 4:28 PM. NA #2 confirmed she was assigned to Resident #9 on 8/26/24 and she provided bedtime incontinence care when Resident #9 rolled out of bed and fell to the floor. NA #2 explained she had Resident #9 turned on her right side, facing away from her as she provided incontinence care, and Resident #9 exclaimed, Oh, I'm falling! and Resident #9 grabbed the side table and rolled off the bed. NA #2 reported prior to providing care to Resident #9 she had not reviewed the Kardex to check if Resident #9 required 1- or 2-person assistance with bed mobility. NA #2 explained Resident #9 was given pain medication after she was assisted back to bed with the mechanical lift, and she did not require any additional care before NA #2 left for the night at 10:30 PM. A nursing note written by Nurse #3 on 8/26/24 at 8:30 PM documented the incident and noted Resident #9 was returned to bed by a mechanical lift and 3-person assistance. The note documented Resident #9 was neurologically intact, and no bruising, lacerations, or injuries were visible. An order dated 8/27/24 written by Nurse #3 ordered an x-ray of the left leg related to pain. A phone interview was conducted with Nurse #3 on 8/29/24 at 1:39 PM. Nurse #3 reported she was the nurse supervisor, and she was working on 8/26/24 when Resident #9 fell out of bed. Nurse #3 explained she had been called to Resident #9's room and found her on the floor, between her bed and the window, lying on her left side. Resident #9 denied hitting her head and did not have any obvious injury, so Resident #9 was put back into bed with a mechanical lift and 3-person assistance. Nurse #3 described Resident #9 as at her baseline neurologically. Nurse #3 reported that Resident #9 had no obvious injuries: no lacerations, no bruising, no deformity of the left leg indicating a fracture, and Resident #9 reported pain between her left lower leg and ankle. Nurse #3 reported she received an order to have an x-ray completed for Resident #9, and when she called the x-ray company, they told her it would be either later 8/26/24 or early 8/27/24 before they arrived. Nurse #3 clarified the order was not STAT (immediate) because there was no obvious indication Resident #9 had a fracture, and the pain medication was effective. A nursing note dated 8/26/24 at 8:52 PM written by Nurse #4 documented Resident #9 received pain medication, hydrocodone/acetaminophen 5 milligrams (mg)/325 mg. A nursing note dated 8/27/24 at 12:04 AM written by Nurse #4 documented the pain medication was effective for Resident #9. A nursing note dated 8/27/24 at 5:47 AM written by Nurse #4 documented that NA #3 was unable to provide incontinence care to Resident #9 because Resident #9 was screaming out in pain. The note documented Resident #9 reported her leg hurt and it felt like her leg was broken. Nurse #4 documented she called the on-call provider and reported the increase in pain and received an order to transfer Resident #9 to the hospital for evaluation. The note documented the resident responsible party was notified of the transfer to the hospital. Nurse #4 was interviewed by phone on 8/29/24 at 9:51 AM. Nurse #4 reported she was working 7:00 PM to 7:00 AM on 8/26/2024 and she was notified by the nursing supervisor (Nurse #3) that Resident #9 had fallen. Nurse #4 reported that when she arrived at the resident's room, Nurse #3 was assessing Resident #9. Nurse #4 described Resident #9 was on the floor on her left side and was not yelling or screaming at that time, but reported her leg hurt and requested pain medication. Nurse #4 reported she provided Resident #9 with her pain medication and when she checked on her later, Resident #9 was asleep. Nurse #4 reported Resident #9 slept all night, but when she was awakened at 5:00 AM by NA #3 for incontinence care, she started to yell and scream in pain. Nurse #4 reported Nurse #5 helped prepare Resident #9 for transfer to the hospital. Nurse #5 was interviewed by phone on 8/29/24 at 2:27 PM and she confirmed she was working 7:00 PM to 7:00 AM on 8/26/2024, but she was not assigned to Resident #9. Nurse #5 reported Resident #9 did not yell out in pain all night, until about 5:00 AM when NA #3 went in to provide incontinence care and then she reported leg pain and then had transferred her to the hospital for evaluation. NA #3 was interviewed by phone on 8/29/24 at 9:44 AM. NA #3 reported she was assigned to Resident #9 on 11:00 PM to 7:00 AM on 8/26-27/2024 and Resident #9 had slept all night. NA #3 described waking Resident #9 for incontinence care around 5:00 AM and when she attempted to remove the covers, Resident #9 started screaming and crying. NA #3 explained she got Nurse #5 and Nurse #4 to come to Resident #9's room and she was transferred to the hospital. The emergency department notes dated 8/27/24 were reviewed. Resident #9 presented to the hospital reporting left knee and thigh pain. The physician assessment documented Resident #9 had full range of motion of her lower extremities and no warmth, deformities or swelling was noted. An x-ray of the left leg revealed an acute intertrochanteric femur fracture with varus angulation (fracture of the upper part of the long bone of the thigh where there was a tilt of the bone inward). An orthopedic surgical consultation was conducted, and Resident #9 was found to have an externally rotated deformity of the left leg (leg was turned outward due to the fracture) and was scheduled to have a surgical fixation of the fracture on 8/28/24. The Director of Nursing (DON) was interviewed on 8/29/24 at 4:51 PM. The DON explained she was notified of the fall and education of NA #2 was given by Nurse #3 on correct turning of a resident during care in bed. The DON reported on 8/27/24 a Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the incident, as well as 100% audit of all resident's care needs and their Kardex's. The DON reported she and the Unit Manager identified 32 residents that required 2-person assistance with Activities of Daily Living (ADL) and the care plans and Kardex's were updated. The DON explained education was initiated for all nursing staff regarding reviewing the Kardex for care needs, as well as safe bed mobility and transfer techniques. The DON concluded by reporting that she and the Unit Manager were observing ADL care with residents that needed 1- or 2-person assistance. The Administrator was interviewed on 8/29/24 at 5:25 PM and he reported he expected the nursing staff used the Kardex to determine the level of assistance a resident requires, and that the care plan and Kardex were current with resident needs.

Based on record review, family, staff, Medical Director, and Pharmacist interviews, the facility failed to ensure a safe and orderly discharge for 1 of 1 sampled resident when Resident #3 was discharged to the community with medications prescribed for another resident (Resident #8) instead of his own medication on 4/9/23. On 4/18/23 Resident #3's Primary Care Physician (PCP) discovered that Resident #3 had been taking multiple medications he was not prescribed and had not taken his own prescribed medications since his discharge from the facility on 4/9/23. Discharging a resident with medications not prescribed for him and without his own prescribed medications had a high likelihood of resulting in serious harm. In addition, the facility failed to have the discharge summary signed by the resident and/or responsible party. Immediate Jeopardy began on 4/9/23 when the facility discharged Resident #3 with another resident's medications in place of his own. Immediate Jeopardy was removed on 10/14/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #3 was admitted to the facility on [DATE]. His cumulative diagnosis included cognitive communication deficit, hypertension (high blood pressure), thrombocytopenia (low platelet levels), and gout (a form of inflammatory arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints). Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #3 was moderately cognitively impaired. Review of Resident #3's electronic records showed the following allergies listed: lisinopril (used to treat blood high blood pressure) and hydrochlorothiazide (used to treat high blood pressure). The type of allergic reactions to the medications were not listed. Review of Resident #3's electronic medical records showed a physician progress note dated 4/7/23 that read in part Made aware resident is discharging on Sunday and needs discharge summary completed please. He will need. home health services for physical therapy, occupational therapy, and speech therapy. He is needing medications sent to the pharmacy of his choice for thirty days. Follow up with outside primary care provider. Review of a social worker note dated 4/7/23 read in part called (family member) to give confirmation of discharge plans - (family member) was not available but I left a detailed voice mail with all information she will need. I spoke with resident as well in regard to discharge plans. Discharge packet will be left with nurse. Review of Resident #3's Discharge Summary dated 4/9/23 showed the following medication orders: - febuxostat 40 milligrams (mg) tablet give one tablet by mouth daily for gout. - metoprolol succinate give one tablet by mouth daily for hypertension - multivitamin tablet give one tablet by mouth daily for supplement. The discharge summary was not signed by Resident #3, Resident #3's responsible party, or the nurse (Nurse #2) who discharged Resident #3. Review of a nursing progress note completed by Nurse #2 dated 4/9/23 at 4:55 P.M. read in part Resident discharge to home with family. All belongings and medications sent with resident and family. Uneventful discharge. Medications reviewed with family and resident prior to departure and further discharge orders also reviewed. All expressed understanding at this time. Review of Resident #3's primary care follow-up visit notes dated 4/18/23 read in part Patient states was discharged on [DATE]. Review of medications patient was discharged on reveals incorrect patient medications. Patient has subsequently been taking clopidogrel [antiplatelet medication that works by preventing clotting factors in the blood from sticking together], carbidopa & levodopa [combination medication used to treat Parkinson's disease symptoms. Levodopa changes into a chemical in the brain to help control muscle movements. Carbidopa prevents the breakdown of levodopa in the bloodstream so more levodopa enters the brain], pantoprazole [decreases the amount of acid in your stomach and used to treat acid reflux and heal stomach/throat ulcers], and methimazole [treats overactive thyroid by stopping the thyroid from making too much thyroid hormone], for the last 2 weeks, none of which he has need for. Uncertain what meds he was actually taking in the Skilled Nursing Facility. Patient's family member reports they did not think anything of the incorrect name because it came with the paperwork with his name on it. Reports the nurse read through each medication and how to take it with the patient and then provided it to them. Patient has taken 9-10 days of these medications. Resident's blood pressure on 4/18/23 at 12:45 P.M. was 134/78 millimeters of mercury (mmHg. (normal systolic blood pressure reading is less than 120 mmHg/ less than 80mmHg). An interview was attempted with Resident #3's Primary Care Physician and was unsuccessful. Review of the prescribing guides listed the following side effects are listed as possible: - clopidogrel: may cause bleeding which can be serious and lead to death, may cause clots to form in blood vessels in as little as two weeks, feeling tired/weak, seizures, fast heart rate or feeling short of breath, headaches, confusion, vision changes, stomach pain, nausea, vomiting, or diarrhea. - carbidopa & levodopa: fatigue, abdominal pain, heart attack, heart palpitations, high or low blood pression, blurred vision, decreased mental acuity, memory impairment, - pantoprazole: headache, diarrhea, nausea, stomach pain, vomiting, gas, dizziness, and joint pain - methimazole: joint/muscle pain, decreased white blood cells, decreased platelets, dizziness, swelling, upset stomach A telephone interview was conducted on 10/3/23 at 10:39 A.M. with Resident #3's family member. Resident #3's family member stated Resident #3 administered medications to himself. Resident #3's family member stated Resident #3 went to his primary care physician (PCP) on 4/18/23 for a follow-up appointment after his discharge from the facility. Resident #3 took the medication the facility had given him to his PCP appointment. During this appointment, the PCP identified Resident #3 had been provided another resident's medications and Resident #3 had taken the wrong medications since his discharge from the facility. Resident #3's family member confirmed Resident #3 was sent home with medications that did not have a label with Resident #3's name on the package and instead had the name of another resident. The family member did not disclose how many medications packages prescribed to another resident were sent home with Resident #3. The family member did state Resident #3 was not sent home with any of the medications prescribed to him when he was discharged from the facility. During the interview, Resident #3's family member provided Resident #8's name and date of birth from the bubble packages sent home with Resident #3. Resident #3's family member explained Resident #3 and the family had recognized there were more medications, but they thought the facility had changed Resident #3's medication while he was a resident at the facility. The family member explained Resident #3 had taken the medications as the nurse had instructed at discharge. Resident #3's family member stated the PCP had concerns about the effects of the blood thinners on Resident #3 due to him having a diagnosis of anemia and labs were drawn at his follow up visit with the PCP to check his blood levels. Resident #3's family member did not have the results from the lab work. Resident #3's family member stated Resident #3 appeared to have increase in weakness, confusion, and gout symptoms after his discharge from the facility. Resident #3's family member did not explain if the symptoms had improved. An interview was conducted on 10/4/23 at 10:21 A.M. with the Social Worker (SW). The SW explained due to the length of time since Resident #3 was discharged , she was unable to recall the specifics of his discharge. During the interview, the SW stated when a resident was scheduled to be discharged on a weekend, she called the family member the Friday prior to discharge and discussed the discharge plan with them. The plan included medical equipment ordered for the resident, any referrals made, and any supportive services in place to assist the resident with the transition back into the community. The SW indicated she placed a copy of the resident's demographic face sheet and the last physician progress note into an envelope and placed the envelope at the nursing station corresponding to the hallway the resident was residing on. The SW further stated nursing staff were responsible for printing a discharge summary, explaining medications, and gathering the medications to send home with the resident at the time of discharge. Review of Resident #8's medical record showed the following physician medication orders active on 4/9/23. - Aspirin (used as a blood thinner to reduce the risk of strokes) 81 one tablet daily - Carbidopa-Levodopa (used to treat symptoms of Parkinson's disease) - 61.25- 245 mg one table by mouth daily - Citalopram (used to treat depression) 40mg tablet give one tablet by mouth daily - Clopidogrel (blood thinner used to prevent strokes and heart attacks) 75mg tablet one tablet by mouth daily - Vitamin B12 (assists to form red blood cells) 500 micrograms (mcg) tablet give one tablet by mouth daily - Pantoprazole (used to reduce the amount of acid the stomach makes) 40mg tablet by mouth daily - Methimazole (used to treat an overactive thyroid) 5mg give one tablet by mouth every other day - Atorvastatin (used to lower bad cholesterol and triglycerides in the blood) 40mg tablet give two tablets by mouth at bedtime. Review of Resident #8's Medication Administration Record for 4/9/23 and 4/10/23, showed Resident #8 received his scheduled medications. A telephone interview was conducted on 10/3/23 at 6:05 P.M. with Nurse #2 who discharged Resident #3 on 4/9/23. Nurse #2 stated when a resident was discharged from the facility, the nurse who completed the discharge was responsible for reviewing all the discharge paperwork included in the discharge packages. These discharge instructions included how to take each medication and to review the medication packages sent home with the resident and/or the resident's family member at the time of discharge. The nurse indicated at discharge the resident and/or the resident's family member should have restated the discharge instructions to confirm they understood the instructions and signed a copy of the discharge summary; the signed copied stayed at the facility and a second copy was provided to the resident and/or the resident's family at the time of discharge. Nurse #2 explained she was asked by a coworker to complete Resident #3's discharge on 4/9/23 and the coworker told her (Nurse #2) Resident #3's medications had been gathered into the bag for his discharge. Nurse #2 was unable to recall who asked her to discharge Resident #3 or who gathered the medication packages into a bag for discharge. During the interview, Nurse #2 stated Resident #3 was not alert and oriented. Nurse #2 went over the discharge instructions with Resident #3's family member as Resident #3's family member was packing up Resident #3's belongings. Nurse #2 explained she did not review any of the medications packages when she gathered the documentations and medications for Resident #3's discharge or when she provided the discharge package and medications to Resident #3's family. The nurse stated she should have checked to see if Resident #3's name was on the medication bubble packages prior to giving the medication to his family. Nurse #2 did not provide a reason for not checking Resident #3's name on the bubble sheets of medication given to Resident #3's family at discharge. A telephone interview was conducted on 10/4/23 at 2:53 P.M. with the Pharmacist. During the interview, the Pharmacist reviewed Resident #8's medical chart and started the pharmacy had filled and sent Resident #8's prescriptions on 4/6/23 and on 4/10/23. The Pharmacist reviewed the notes in Resident #8's chart and stated there was not a note written about why the facility had requested all of Resident #8's medications to be refilled four days after the pharmacy had sent the facility his prescriptions. During the interview, the Pharmacist was unaware Resident #8's medication had been sent home with another resident at discharge. The Pharmacist explained the facility had a backup pharmacy on-site with most of the medications Resident #8 was prescribed available for administration. During the interview the Pharmacist explained medications were prescribed by a provider for very specific medical conditions and an individual should never take another individual's medications without first consulting their medical doctor. The Pharmacist explained medication reactions varied from person to person and the dosing of medications could affect these reactions. The Pharmacist did not provide possible outcomes for Resident #3 due to taking medications prescribed to Resident #8 after he was discharged from the facility. An interview was conducted on 10/4/23 at 12:49 A.M. with the Medical Director. The Medical Director reviewed the list of medications for both Resident #3 and Resident #8. After reviewing the list of medications, the Medical Director explained there should be no significant medical effects on Resident #3 after taking Resident #8's medications for nine days or for not taking his prescribed medications for the nine days. During the interview, the Medical Director stated Resident #3 should have been sent home with the medications prescribed to him and not another resident's medications. The Medical Director was unable to state how this error occurred, but stated he felt like it was a mistake made by the nursing staff during Resident #3's discharge. An interview was conducted on 10/4/23 at 1:23 P.M. with the Director of Nursing (DON). During the interview, the DON stated a resident being sent home with another resident's medications should not have occurred. The DON explained the nurse who discharged Resident #3 from the facility had the responsibility to review both the list of medications and the bubble packages of medication with Resident #3 and/or his responsible party prior to him being discharged from the facility. The DON stated she had no explanation to how Resident #3 was sent home with another resident's medication. An interview was conducted on 10/4/23 at 2:50 P.M. with the Administrator. During the interview the Administrator stated bubble packages of medications should never leave the facility with a resident who was not prescribed the medication. The Administrator stated it's not the facility's normal practice to send medication home with residents at discharge, unless the medications were sent home due to insurance requirements, and he is unsure how this mix-up occurred. The Administrator was notified of the Immediate Jeopardy on 10/12/23 at 2:51 P.M. On 10/13/23 the facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: On 4/9/2023 Universal Healthcare of Concord discharged Resident #3 home with wrong medication. Nurse #1 failed to review medication list and compare it with the actual medication with family and have it signed by family or Resident #3. Resident #3 was discharged home with family on 4/9/23. The discharge summary dated 4/9/23 indicated Resident #3 was prescribed a medication for gout, hypertension, and a multivitamin. The discharge summary was not signed by the resident, family member or the nurse that discharged the resident. When Resident #3 was seen by his Primary Care Physician on 4/18/23 it was discovered Resident #3 had been taking medications prescribed to Resident #8 since his discharge from the facility on 4/9/23. On 10/3/2023 upon learning of the alleged incident the Director of Nursing began re-educating all licensed nurses on discharge process to include, all discharges home medications are to be signed and reviewed by 2 nurses prior to discharging residents with medications. All residents discharged home with medications are at risk of being affected by this alleged deficient practice. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: The complete audit of all discharges home to ensure that all medications lists had been reviewed and signed by family and discharging nurse as of 4/9/2023 has been completed by Social Worker and Director of Nursing as of 10/13/2023. As of 10/13/2023 Director of Nursing re-educated all nurses on facility policy for discharge and sending medications home as of 10/13/2023. All nurses were educated to review medications with family prior to discharge and have family sign discharge medication list as of 10/13/2023. The medication list and discharge medication packets will be reconciled by two nurses and family prior to discharge as of 10/13/2023. All new hires will be educated on discharge medication process prior to starting their first shift by the Director of Nursing as of 10/13/2023. The facility does not use agency staffing. Allegation of Immediate Jeopardy removal date: 10/14/23 The credible allegation was verified on 10/17/23 through interviews conducted with nursing staff that showed they had received training about discharge procedure, all discharged medications are to be signed and reviewed by two nurses prior to discharging residents' home with medications. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were viewed, staff names were randomly selected and verified to have received training. A newly hired nurse was verified to have received discharge training by the Director of Nursing. A review of discharges from 4/9/23 through 10/13/23 identified no concerns. The facility had one discharge on 10/14/23. The responsible party refused to go to the facility to sign discharge paperwork. Medications were reviewed with the responsible party via telephone with two nurses. The facility's immediate jeopardy removal date of 10/14/23 was validated.

Based on record review, observations, physician and staff interviews, the facility left a cognitively impaired resident unsupervised outside on the facility's front porch (Resident #4) and failed to prevent another cognitively impaired resident from exiting the facility without supervision (Resident #1) for 2 of 3 residents reviewed for accidents. Resident #4 expressed a desire to leave the facility and an elopement risk assessment was not completed by staff. On 1/13/2019 staff assisted Resident #4 outside in his wheel chair and left him unsupervised on the front porch in 30 degree Fahrenheit weather and he self-propelled his wheel chair 50 feet from the facility's front doors before staff saw him and brought him back inside the facility. Resident #1 exited the building on 1/30/2019 in 30 degree Fahrenheit weather dressed in pants and a t-shirt while unsupervised and self-propelled his wheelchair 72 feet to the end of the sidewalk before staff was notified by an anonymous phone call that informed staff the resident was outside the facility without supervision. Residents #1 and #4 were returned inside the facility without injuries. Immediate jeopardy began on 1/13/2019 when Resident #4 was assisted outside to the facility's front porch by a staff member and left unsupervised and while he was unsupervised he self-propelled his wheelchair 50 feet to the wheelchair ramp when staff arrived and returned him to the facility. Immediate Jeopardy continued when Resident #1 exited the facility through two sets of doors and while unsupervised self-propelled his wheelchair 72 feet before staff returned him to the facility. Immediate Jeopardy was removed on 2/21/2019 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. Findings included: 1. Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. A review of care plans for Resident #4 revealed care plan in place for wandering or potential elopement was not developed until after 1/13/2019. A nursing note dated 1/5/2019 at 7:43 PM written by Nurse #4 documented Resident #4 was attempting to get out of bed and he stated, I'm going to get out of bed and go outside to smoke. Nurse #4 documented she reassured Resident #4, instructed him to use his call bell for assistance to transfer and his call bell was in reach. Nurse #4 was interviewed on 2/20/2019 at 9:44 AM. Nurse #4 reported she had been assigned to provide care to Resident #4 on 1/5/2019 on 2nd shift (3:00 PM to 11:00 PM) and she had written the note documenting Resident #4 had expressed a desire to leave the facility and she had reported his behavior to UM #1. Nurse #4 reported she had not completed an elopement risk for Resident #4 because he was not getting out of the bed on 1/5/2019 due to his recent hospitalization . Nursing notes for Resident #4 were reviewed and a note dated 1/6/2019 at 11:40 AM written by Nurse #1 documented a statement made by Resident #4, I'm going to get up and walk and leave here, I don't care what anyone says. Nurse #1 documented she told Resident #4 he was not able to walk because of the weakness on his left side and Resident #4 replied, Your (sic) lying, that's not true. Nurse #1 documented she reassured Resident #4 and he calmed down. Nurse #1 was interviewed on 2/20/2019 at 10:52 AM and she reported she was assigned to provide care to Resident #4 on 1/6/2019 and she had documented Resident #4 had made statements about leaving the facility. She reported she did not complete an elopement risk assessment on 1/6/2019 when the resident expressed a desire to leave the facility because he was not getting out of the bed on that date because he had a stroke and was unable to move the left side of his body. Nurse #1 further stated she had reported to UM #1 about Resident #4's statement regarding leaving the facility. An elopement risk assessment completed by Unit Manager (UM) #1 dated 1/8/2019 was reviewed. This assessment did not identify Resident #4 as an elopement risk, but answers to some of the questions on the assessment found to be inaccurate. The question Has the resident expressed the desire to go home was checked no. The question have there been any changes to the resident's status was not included in the elopement assessment completed 1/8/2019. An interview was conducted with UM #1 on 2/20/2019 at 12:44 PM. UM #1 reported she did not recall receiving report from Nurse #4 on 1/5/2019 or Nurse #1 on 1/6/2019 regarding Resident #4's statements about leaving the facility. UM #1 reported she completed the elopement risk assessment on 1/8/2019 and did not consider him a risk for elopement because he had not attempted to leave the building in the past, and he had not stayed around the exit doors waiting for the doors to open, so he could leave. UM #1 reported elopement risk assessments were completed quarterly and as needed and because Resident #4 was not getting out of bed due to a stroke, he was not an elopement risk. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 and wandering behaviors noted. The MDS assessed Resident #4 to require extensive 2-person assistance to transfer and he was non-ambulatory, using a wheelchair for all locomotion. Resident #4 was assessed to have adequate vision and hearing and he was able to be understood by others and was assessed to be able to understand others. Resident #4 required limited one-person assistance with locomotion on the unit and was assessed to be independent with locomotion off the unit. Resident #4 was assessed to require total one-person assistance with dressing. A nursing note written 1/13/2019 at 5:30 PM by Nurse #3 documented nurse was called to lobby . receptionist pushed resident (#4) out onto the porch and had stated to the receptionist he want(ed) to go outside for a minute because he was 'leaving this place'. Resident (#4) assisted back into the building by the receptionist after staff educated the resident he could not go outside unassisted. Resident (#4) stated he does not want to be here, that he wants to go home . received phone call from the administrator to start 30 min checks and apply a wanderguard to resident. Resident (#4) stated . if a wanderguard was going to be applied, he would find a way to cut it off. Staff monitoring resident as ordered. An interview was conducted with Receptionist #2 on 2/19/2019 at 3:25 PM via phone call. Receptionist #2 reported he worked the evening of 1/13/2019 and Resident #4 had approached the receptionist desk after 4:00 PM and asked Receptionist #2 to assist him outside because he wanted to wait for a family member. Receptionist #2 went on to explain Resident #4 was fully dressed and had a coat with a hood on and the hood was up on his head. Receptionist #2 asked Resident #4 if he had talked to his assigned nurse and Resident #4 reported he had told the nurse he was going out for supper. Receptionist #2 reported he assisted Resident #4 to the covered front porch and placed him in an area where Receptionist #2 could view him. Receptionist #2 went on to explain he had gotten busy with something at the desk and when he looked up, Resident #4 was no longer in his sight, so he went out onto the front porch and discovered Resident #4 was self-propelling his wheelchair on the sidewalk and was at the wheelchair ramp 50 feet from the front doors. Receptionist #2 estimated Resident #4 was outside for approximately 15 minutes. Receptionist #2 reported the role of the receptionist was to monitor the front door for residents and visitors and to identify residents at risk for elopement from the wanderguard book that was at the front desk. Receptionist #2 reported Resident #4 was not in the wanderguard book and he had not contacted Resident #4's nurse to confirm he could leave the building. On 2/20/2019 at 4:21 PM Receptionist #2 showed where he placed Resident #4 in his wheelchair on the facility porch on 1/13/2019. Observations of the area revealed a covered porch area of the facility measured approximately 27 feet by 26 feet and was open on three sides with pillars which supported the roof. The concrete of the porch area was smooth without cracks or uneven areas. During the observation of the porch, Receptionist #2 showed where Resident #4 had self-propelled his wheelchair. This area was observed and revealed a wheelchair ramp on the east side of the porch exited into the parking area of the facility approximately 50 feet from the front doors and where Resident #4 was left by Receptionist #2. The parking lot was asphalt with some uneven areas noted beyond the wheelchair ramp. Weather.com documented the weather on 1/13/2019 for the city the facility is located specified a high of 32 degrees Fahrenheit, low of 5 degrees Fahrenheit, and sunny. An interview was conducted with Resident #4 on 2/19/2019 at 4:32 PM. Resident #4 reported he did not recall the incident of 1/13/2019. An interview was conducted with Nurse #3 on 2/20/2019 at 9:26 AM. Nurse #3 reported she was assigned to provide care to Resident #4 on 1/13/2019 and she had been notified by Receptionist #2 that Resident #4 had been assisted outside, but he tried to self-propel his wheelchair away from the facility. Nurse #3 reported she alerted the Administrator and had received guidance to complete an elopement assessment and apply the wanderguard if it was appropriate. Nurse #3 further reported she conducted checks on the resident and there were no adverse effects noted from him being outside. The medical record was reviewed and on 1/13/19 at 6:41 PM Resident #4's vital signs were documented as temperature of 97.0 degrees Fahrenheit, pulse 72, respirations 22, and blood pressure 130/64. An interview was conducted with NA#9 who was assigned to Resident #4 on 1/13/2019 for 2nd shift (3:00 PM to 11:00 PM). NA #9 reported Resident #4 was fully dressed upon her arrival for her shift and that he liked to be dressed in pants, shirt and a hoodie jacket because he smoked. NA #9 reported Resident #4 had not specifically stated on that date he was going to leave, but he had made statements in the past regarding wanting to go home. NA #9 reported she was not concerned by Resident #4's statements and did not inform the nurse. The Assistant Director of Nursing (ADON) was interviewed on 2/20/2019 at 12:58 PM. The ADON reported she had heard Resident #4 had expressed a desire to leave the facility, but she was not certain of the date he made those statements. The ADON reported she completed an elopement risk assessment the day after he attempted to leave and assessed him to be an elopement risk because he had attempted to leave the building. The ADON reported an elopement risk assessment should have been completed for Resident #4 on 1/5/2019 or 1/6/2019 after Resident #4 made statements about wanting to leave the facility. The ADON concluded by reporting if the elopement risk assessment completed on 1/8/2019 had included accurate information about Resident #4, including his statements to leave the building and the recent change in his health status, and he was found to be an elopement risk, a care plan would have been developed. The Social Worker (SW) was interviewed on 2/20/2019 at 3:28 PM. The SW reported she had completed the sections of the quarterly MDS dated [DATE] regarding behaviors and she coded Resident #4 as having wandering behaviors, but that was an error and she had corrected the coding for the MDS. The facility physician (DO) was interviewed via phone call on 2/20/2019 at 5:21 PM. The DO reported the resident had told her that he went outside on 1/13/2019 because he wanted to go outside. The DO went on to explain Resident #4 had been egged on by his roommate to leave the facility and he had went outside as an act of defiance. The DO reported she felt Resident #4 was showing poor judgment when he went outside. The DO reported Resident #4 was not safe and did not make safe judgments. The Administrator was interviewed on 2/21/2019 at 12:11 PM and she reported she received a phone call from Receptionist #2 on 1/13/2019 to report Resident #4 had lied to him and had been taken outside by Receptionist #2. The Administrator reported she had talked to the nurse and recommended performing an elopement assessment and applying a wanderguard if needed. The Administrator reported she was not certain if the incident was discussed at the daily morning meeting or if the team discussed the incident. The Administrator reported she did not know Resident #4 to know if he made poor judgements and he seemed to be alert and oriented. 2. Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. An elopement risk assessment dated [DATE] was reviewed and Resident #1 was assessed as an elopement risk due to cognitive impairment, a pertinent diagnosis, communication problems and he had expressed a desire to leave the facility. A care plan dated 7/16/2018 assessed Resident #1's risk for falls, and the stated problem documented he is impulsive and forgets to ask for assistance due to memory deficit. Interventions for the fall care plan included to reassesses quarterly and with any change of condition and to encourage Resident #1 to be in common areas when he was out of bed. A care plan that addressed Resident #1's attempt to leave the building without staff assistance with the goal will not attempt to exit the building on his own was marked as achieved on 7/4/2018 and was not active from 7/4/2018-1/31/2019. An elopement risk assessment completed by Nurse #2 and dated 10/11/2018 assessed Resident #1 not at risk for elopement. An interview was conducted with Nurse #2 on 2/18/2019 at 4:04 PM via a phone call. Nurse #2 reported she completed the elopement risk assessment on Resident #1 on 10/11/2018 and because he was not getting out of bed or leaving his room, she assessed him to be not at risk for elopement. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired Brief Interview for Mental Status (BIMS) score of 9. No physical behaviors, rejection of care or wandering were noted on the MDS of 12/22/2018. The MDS assessed Resident #1 to be totally dependent on 2-person assistance for transfers and he was non-ambulatory, and dependent on 1-person assistance for locomotion. Review of Resident # 1's medical record revealed no elopement risk assessments were completed between 10/12/2018 and 1/30/2019. The Assistant Director of Nursing (ADON) was interviewed on 2/20/2019 at 12:58 PM. The ADON reported she was working the day Resident #1 got out of the building, but she did not observe him outside. The ADON reported UM #1 had reported to her Resident #1 had gotten outside and the receptionist was made aware Resident #1 was outside by a phone call from a visitor. The ADON reported Resident #1 had been in bed and not mobile for several months, but physical therapy had provided treatment for [REDACTED]. The ADON was not certain of the length of time he had been using the high-back wheelchair. The ADON further reported that based on Resident #1's previous behaviors of attempting to leave the building, an elopement risk assessment should have been completed when he returned to his baseline level of activity during the month on (MONTH) 2019, but staff failed to reassess the resident's risk of elopement prior to his unsupervised exit from the facility on 1/30/19. A nursing note written by Nurse #1 and dated 1/30/2019 at 2:24 PM noted Resident #1 at the front desk, noted following transportation company out front door, staff went and encouraged resident back inside without any problems, wanderguard placed to right ankle for safety; notified Responsible Party. Vital signs for Resident #1 on 1/30/2019 at 1:40 PM were documented as temperature of 97.9 degrees Fahrenheit, pulse 74, respirations 20 and blood pressure 144/80. Nurse #1 was interviewed on 2/20/2019 at 10:52 AM and she reported on 1/30/19 she arrived at the front lobby as Resident #1 was being brought back in the building and she did not go outside to get him. A nursing assistant (NA) #1 was interviewed on 2/19/2019 at 10:01 AM. NA #1 reported she had been assigned to Resident #1 on 1/30/2019. NA #1 went on to explain she had tried to find Resident #1 to assist him into bed to perform incontinence care, but she could not locate him. NA #1 reported she went around the inside of the building twice to find Resident #1 and notified NA #3 and Nurse #1 she could not find Resident #1. NA #1 then explained when she got to the front lobby, she was told by Receptionist #1 Resident #1 was outside and NA #1 went out to retrieve him. NA #1 reported Resident #1 was dressed in a short-sleeve t-shirt, pants that were rolled up to his knees and a baseball cap on 1/30/2019. NA #1 estimated Resident #1 was missing for approximately 15 minutes. Receptionist #1 was interviewed on 2/21/2019 at 11:27 AM and she reported she noticed Resident #1 pass by the front desk on 1/30/2019 and she thought he was going out with transportation staff. Receptionist #1 stated she did not notice how Resident #1 was dressed. Receptionist #1 reported she did not observe Resident #1 after he went through the double doors to the patio. She stated that she received a phone call from a visitor who reported there was a resident on the walkway in front of the facility. Receptionist #1 reported she was not aware Resident #1 was outside the facility unsupervised until she received the phone call. Receptionist #1 reported as she received the phone call, the Dietary Manager (DM) was walking up front. Receptionist #1 reported she had signaled for the DM to go outside. The Central Supply manager (CSM) also arrived at the front desk and Receptionist #1 told her to go outside to help DM. Receptionist #1 concluded by reporting that she was not certain who brought Resident #1 in from outside and she wasn't certain how long he had been outside. A driver for the transportation company was interviewed on 2/20/2019 at 11:21 AM. The driver reported she was picking up a resident for an appointment on 1/30/2019 and as she and the resident were attempting to leave, Resident #1 was in front of them going through the front doors. The driver reported no alarm sounded when Resident #1 went through the front doors. The DM was interviewed on 2/21/2019 at 11:40 AM and she reported that when she went to the front desk to give invoices to Receptionist #1, the DM was signaled by Receptionist #1 to go outside. She noted Receptionist #1 was on the phone. The DM went on to explain she did not see anyone when she exited the building and she walked to the end of the covered porch and looked right and then left and saw Resident #1 at the end of the walkway. The DM reported she did not remember which staff members came out to assist her to bring Resident #1 back into the building. The CSM was interviewed on 2/21/2019 at 11:00 AM. She reported she was passing through the front lobby on 1/30/2019 when Receptionist #1 told her to go help the DM. The CSM reported she stepped out to the covered porch and did not see Resident #1, but when she walked to the end of the porch, she could see Resident #1 on the walkway and the DM had her arms around his upper body. CSM reported Resident #1's front wheel on his wheelchair was off the end of the sidewalk and the DM was holding him from falling. CSM further reported she lifted the wheelchair back onto the walkway and by then Nurse #1, NA #1 had arrived, and they escorted Resident #1 back into the building. An interview was conducted with NA #2 on 2/20/2019 at 10:19 AM. NA #2 reported she was working in the dining room on 1/30/2019 and it was lunch time. She looked out of the dining room windows and saw Nurse #1, NA #1 and the UM #1 at the end of the walkway outside with Resident #1. NA #3 was interviewed on 2/20/2019 at 10:29 AM and she reported she was working 1/30/2019. She further reported she had been told by NA #1 that Resident #1 was missing and NA #3 started to search the building for him and when she arrived in the front lobby, Resident #1 was being brought in through the front doors by NA #1, Nurse #1 and UM #1. NA #4 was interviewed on 2/21/2019 at 9:15 AM. NA #4 reported she was working in the dining room on 1/30/2019 and she observed the DM running down the walkway in front of the dining room windows. NA #4 reported she saw Nurse #1, NA #1 and Central supply manager outside with Resident #1. NA #4 concluded by reporting that she and NA #3 watched staff bring Resident #1 in from outside through the dining room windows. Resident #1 was observed on 2/18/2019 at 4:15 PM independently self-propelling his wheelchair in the halls of the facility using his feet. He was observed to be able to maneuver around other residents and obstacles. Resident #1 was interviewed on 2/19/2019 at 11:33 AM and he was unable to recall the incident. Resident #1's family member was in the room and she reported she was not aware Resident #1 had been outside without supervision and she had been notified only that a wanderguard was applied to him due to wandering behaviors. The rehabilitation director (RD) was interviewed on 2/21/2019 at 9:25 AM. The RD reported physical therapy had started treatment with Resident #1 in (MONTH) (YEAR) because he was having back pain and he was not able to support himself in the wheelchair. The RD reported physical therapy had worked with Resident #1 to improve his back strength and had introduced him to a high-back wheelchair at the beginning of (MONTH) 2019 and once Resident #1 had back support, he was able to independently self-propel the wheelchair in the facility. The RD further explained that Resident #1 had poor endurance, but if he was determined to get somewhere in his wheelchair, he would do it. Unit Manager (UM) #1 was interviewed on 2/21/2019 at 10:38 AM. UM #1 reported the incident with Resident #1 was discussed at the interdisciplinary team meeting the next day. She further reported she was completing elopement risk assessments, but nursing staff were being trained to complete the assessments. She reported Resident #1 had a change in his level of activity for several months and he was assessed to not be an elopement risk. UM #1 reported she knew therapy had given Resident #1 a high-back wheelchair, but she was not aware he was able to self-propel the wheelchair. NA #1 was interviewed on 2/21/2019 at 9:44 AM. NA #1 showed where on the walkway Resident #1 was located after he left the building and the distance was measured with the Maintenance Director and the facility's Regional Director of Operations. The distance between the front double doors and where Resident #1 was found was 72.5 feet. The walkway in front of the facility dropped off approximately 6 inches into the parking lot, which sloped downward. Multiple areas were noted with broken asphalt. NA #1 reported she had searched for Resident #1 and was unable to locate him, and when she arrived at the front lobby, she was told a visitor had called to report a half-dressed resident was outside on the walkway. NA #1 reported she, the Central Supply manager and another person assisted Resident #1 back into the facility and she then assisted him back to bed. Weather.com documented weather on 1/30/2019 for the city the facility is located specified high of 31 degrees Fahrenheit and a low of 5 degrees Fahrenheit and partly cloudy. The facility physician (DO) was interviewed via a phone call on 2/20/2019 at 5:21 PM. The DO reported Resident #1 is not safe to be outside unsupervised. The DO went to report she had assessed Resident #1 on 1/31/2019 and he did not have any adverse effects from being outside. The Administrator was interviewed on 2/21/2019 at 12:11 PM. The Administrator reported she was notified by the DON that Resident #1 had gone out onto the front porch and he was brought back into the building by staff. The Administrator reported she had called the facility consultant and after discussion with the consultant, they determined it was not an elopement because Resident #1 had expressed a desire to get fresh air and he did not have wandering behaviors. The Administrator concluded by reporting she did not believe Resident #1 was unsafe, but she did not know him well enough to determine if Resident #1 made good decisions. The Administrator, Director of Nursing, Chief Clinic officer, Regional Clinical Consultant and Regional Director of Operations were notified of Immediate Jeopardy on 2/21/2019 at 2:12 PM. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 2/22/2019. Date: 02/21/2019 Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #4 exited the facility on 1/13/2019 at approximately 04:15PM through the front door of the facility. Resident #4 was assisted to the front porch by the facility receptionist #1 upon his request. Review of resident #4's Brief Interview for Mental Status (BIMs) assessment completed on 11/30/2018 indicated resident #4 scored 14 which is interpreted as alert and oriented. Resident #4 was also coded in MDS assessment with assessment reference date 12/21/2018 indicated resident can make himself understood and understand others always. Likewise; quarterly MDS assessment dated [DATE] noted BIMS of 11 which is moderately impaired. Interview with receptionist #1 conducted by the facility Administrator on 2/21/2019 indicate that resident #4 was outside for about 7-10 minutes. Resident #4 is not deemed incompetent and is able to make his decision and has rights to come and go in and out of the facility as he's pleased. Elopement risk assessment completed on 01/08/19 indicates resident was not at risk for elopement hence, the facility maintained resident#4 rights to go and come as he is pleased based on the assessment and per resident's bill of rights. Licensed nurse #1 walked to the front lobby after being summoned by the receptionist #1. Receptionist #1 walked outside and observed resident #4 on the side walk 50 feet from the location where the resident was placed originally. Receptionist #1 assisted resident #4 back to the facility through the front door. Licensed nurse #1 rolled resident #4 to his room and completed a head to toe assessment and noted no changes from his baseline. Licensed nurse #1 contacted attending physician and resident #4 responsible party on 1/13/19 to notify them of resident #4 action of exiting the facility. A Licensed nurse #1 completed an elopement risk assessment and deemed resident #4 to be at risk for elopement on 1/13/2019, wander/elopement alarm obtained and applied to resident #4 right ankle by licensed nurse #1. Resident #1 exited the facility on 1/30/2019 at approximately 01:15PM through the front door of the facility. Receptionist #2 witnessed resident #1 exiting the facility in the midst of the multitude. (The multitude included the staff members from a contracted transportation company that was exiting the facility). Review of resident #1's Brief Interview for Mental Status (BIMs) assessment completed on 12/21/2018 indicated resident #1 scored 9 (moderately impaired cognition) Resident #1 was also coded in MDS assessment with assessment reference date 12/22/2018 indicated resident #1 can make himself understood, and usually understand others. Review of section E of MDS assessment with ARD 12/22/2018 indicate resident #1 does not have wandering behaviors. Receptionist #2 called the licensed nurse #2 to alert the nurse that resident #1 was at the front porch. Interview conducted by the facility Administrator on 2/21/2019 to receptionist #2 and Dietary manager indicated; receptionist #2 received a phone call from the visitor who was leaving the facility. The caller indicated resident #1 was observed outside. Dietary manager walked outside immediately while the receptionist #2 was still on the phone and observed resident #1 approximately 72 feet away from the front door. All four wheels were on the side walk. Receptionist #2 indicated that resident #1 was outside for approximately less than 10 minutes. Licensed nurse #2 walked to the front porch and assisted resident #1 back to the facility. Licensed nurse #2 notified Assistant Director of Nursing (ADON) that resident #1 was at the front porch. ADON completed an elopement risk assessment and deemed resident #1 to be at risk for elopement on 2/21/2019. Unit Manager #1 notified resident #1 attending physician and licensed nurse #2 notified resident #1 responsible party on 2/21/2019. New order for wander/elopement device obtained and applied to resident's right ankle by licensed nurse #2 on 2/21/2019. Unit Manager #1 updated resident #1 care plan and added wander/ elopement device in place on 2/21/2019. Receptionist #1 and #2 were hired to work at the facility on 09/11/18 and 07/02/2018 respectively. Although both receptionists were educated on the facility elopement management process upon hire, it is concluded that the emphasis on their responsibilities pertaining to elopement management process wasn't well understood. Receptionist #1, and #2 were re-educated by the facility administrator on 2/21/2019 on the importance to ensure that the licensed nurse who care and familiar with the resident who is requesting to go outside is contacted to validate whether the resident is safe to go outside or not. Effective 2/21/2019, and moving forward the facility implemented the process of signing residents out when leaving the facility for an appointment. The transportation company employee will sign the resident out at the front desk before leaving the facility. All transportation company employees will be educated on this requirement before transporting the next resident from the facility effective 2/21/19 Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. 100% of Elopement risk assessments for all current residents completed on 02/21/2019, by the Assistant Director of Nursing, to identify any other residents who might be at risk for exit seeking behaviors. Six other residents who were previously identified to be at risk for elopement, re-identified during this assessment, Elopement books revised and placed at the front desk, and at each nurse's station by Director of Nursing, Assistant Director of Nursing and/or Unit Manager #1 on 2/21/2019. These books contain a list of residents with exit seeking behaviors, their pictures and resident's descriptions. The Elopement books are located in a place accessible to all staff for easy identification of elopement risk residents (at the front desk, and at each nurse's station). Measures/Systematic changes made to ensure that the deficient practice will not re-occur Effective 2/21/2019, and moving forward, licensed nurses will complete elopement risk assessments for all residents on admission/re-admission, quarterly, with any significant changes of resident's condition, and/or whenever a resident is noted to exhibit exit seeking behaviors/attempts; to include but not limited to, behaviors of wandering aimlessly, cognitively impaired residents expressing desire to go home, packed belongings to go home, stayed near an

Based on record review, resident and staff interviews, the facility failed to treat residents with respect and dignity for 1 of 3 residents reviewed for dignity as evidenced by an alert and oriented resident who was left in fecal matter (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set ((MDS) dated [DATE] assessed Resident #2 to be cognitively intact without behaviors and rejection of care noted 1-3 days. The MDS assessed Resident #2 to require extensive 2-person assistance with toileting and Resident #2 was frequently incontinent of bowels. The MDS assessed Resident #1 to have adequate vision and hearing. The care plans for Resident #2 were reviewed and a care plan was in place dated 11/30/2018 that identified Resident #2 was at risk for skin breakdown and interventions included to provide incontinent skin care after each incontinent episode. A care plan dated 11/30/2018 and reviewed on 2/18/2019 addressed bowel incontinence for Resident #2 and goals were Resident #2 would be clean, dry and odor-free daily and no signs or symptoms of infection related to incontinence. Interventions for the care plan included provide incontinence care after each incontinence episode. Resident #2 was interviewed on 2/18/2019 at 5:04 PM. Resident #2 reported he had bowel movements first thing in the morning or in the middle of the night and he knew he needed to have a bowel movement but did not always have a lot of warning. Resident #2 reported he was not certain of the date, but it was about 3:00 AM. He reported he used the call light to ask for assistance, but before staff arrived, he had a bowel movement. He further reported he was unable to move his body and laid in feces for almost 30 minutes. Resident #2 pointed to the clock on the wall beside his bed and reported he was able to see the clock and keep track of time. Resident #2 also reported he used his cell phone to keep track of time. He went on to explain that the incident made him feel ashamed because he needed assistance with cleaning himself and angry because no staff would come to help him. Resident #2 was unable to recall the name of the staff who was assigned to provide him care that night. The Director of Nursing was interviewed on 2/22/2019 at 7:39 PM and she stated it was her expectation that dignity was maintained for all residents at the highest level. The Administrator was interviewed on 2/22/2019 at 7:52 PM and she reported it was her expectation that issues were resolved to allow all residents to have a dignified existence.

Based on record review, observations, staff interview and resident interview the facility failed to provide sufficient nursing staff to provide incontinence care and answer call bells for 1 of 3 sampled residents reviewed for dignity(Resident #2). Findings included: This tag was crossed referenced to: F 550: Based on record review, observations resident and staff interviews, the facility failed to treat residents with respect and dignity for 1 of 3 residents reviewed for dignity as evidenced by an alert and oriented resident who was left in fecal matter (Resident #2). Nursing assistant (NA) #7 was interviewed on 2/17/2019 at 6:30 AM. NA #7 reported she worked 3rd shift (11:00 PM to 7:00 AM) and she is assigned to 30+ residents for care during her shift and it was difficult to answer call bells in a timely manner. NA #7 concluded by reporting residents complained about the time it took for staff to answer their call bells during 3rd shift. Nurse #7 was interviewed on 2/17/2019 at 6:40 AM and she reported she usually worked 2nd shift (3:00 PM to 11:00 PM) but she was working over to help because of low staffing. Nurse #7 reported 2nd shift had very poor staffing, and it was a skeleton crew and it was difficult for the NA to answer call bells in a timely manner. An interview was conducted with NA #6 on 2/17/2019 at 6:50 AM. NA #6 reported she had worked 3rd shift with one other NA for a total of 2 NA for the entire building. NA #6 reported when staffing was low it was difficult to get all the work completed and difficult to answer call bells. NA #8 was interviewed 2/17/2019 at 6:54 AM and she reported she worked all 3 shifts at the facility and stays over to help the next shift. NA #8 further reported residents waited a long time for their call bell to be answered because there were not enough staff to provide care to all residents and she had 32-35 residents in her assignment. The Director of Nursing (DON) was interviewed on 2/22/2019 at 7:39 PM and she reported she had hired staff and they were in orientation. The DON reported she was aware residents were unhappy with the timeliness of call bell response from the staff. The Administrator was interviewed on 2/22/2019 at 7:52 PM and she reported it was her expectation the facility had adequate staff to meet the needs of the residents.

Based on record review, observations and staff interviews, the facility failed to provide supervision for to prevent a cognitively impaired resident from exiting the facility (Resident #1) for 1 of 3 residents reviewed for supervision. Resident #1 exited the facility while unsupervised and self-propelled her wheelchair 29 feet to the end of the sidewalk and fell to the asphalt pavement of the parking lot, sustaining a fractured nose, abrasions to her face, hands and knees and a laceration to her left forehead, as well as bruising to her face. Immediate jeopardy began on 5/6/2018 when Resident #1 exited the facility through two sets of doors while unsupervised and self-propelled her wheelchair 29 feet to the end of the sidewalk and fell to the asphalt pavement of the parking lot, sustaining a fractured nose, abrasions to her face, hands and knees and a laceration to her left forehead, as well as bruising to her face. The Immediate Jeopardy was removed on 5/9/2018 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An elopement risk assessment was completed on 3/27/2018 and Resident #1 was assessed to be at risk for elopement with potential risk factors identified as cognitive impairment and poor decision-making skills, a [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Check every shift. There was no time stamp on the order. A handwritten physician order [REDACTED]. DC (discontinue) previous wanderguard orders. There was no time stamp on the order. The Medication Administration Record [REDACTED]. An order was noted on the MAR indicated [REDACTED]. Nurse ' s initials on the MAR for 3/8-3/31/2018 and 4/1-9/2018 indicated this task was completed. The care plan for wandering behaviors dated 3/27/2018 was reviewed. The care plan specified observation of the resident when out of bed to determine whereabouts, redirection of the resident, apply wanderguard to right lower extremity and check the wanderguard device for function and placement per facility protocol. The care plan goal for wandering stated, resident will wander safely throughout building with direction of staff through next review. The care plan was updated on 3/27/2018 with the handwritten notation d/c (discontinue) WG (wanderguard) no longer at risk. The care plan was again updated on 3/31/2018 during the quarterly review and the handwritten statement read WG has been d/c ' d. An elopement risk assessment dated [DATE] was reviewed and Resident #1 was assessed to not be at risk for wandering and interventions included frequent monitoring. Resident #1 was assessed to not be at risk for elopement with potential risk factors identified as cognitive impairment and poor decision-making skills, a [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed the resident to be severely cognitively impaired with the need for extensive assistance for bed mobility, transfers, dressing, toileting, hygiene and bathing. The resident was unable to maintain her balance and required the assistance of staff. The resident required a wheelchair for mobility. A nursing note written by Nurse #4 dated 4/30/2018 documented behaviors (undressing in the hall, combativeness towards staff) by the resident. A nursing note dated 5/1/2018 written by Nurse #4 documented Resident #1 wandering into other resident rooms. An elopement risk assessment completed by Nurse #2 dated 5/4/2018 was reviewed and Resident #1 was assessed to be not at risk for elopement. The note did not specify if Resident #1 was exhibiting any wandering or exit-seeking behaviors. A nursing note dated 5/6/2018 at 11:33 AM documented that staff were called to the front door at approximately 11:15 AM. The resident was observed outside the facility, face down on the pavement and the wheelchair was on the sidewalk. The resident was bleeding from her face and hands. The nurse documented she contacted emergency medical services (EMS) and a family member, as well as the Director of Nursing (DON), the Administrator and the on-call physician. A fall incident report dated 5/6/2018 noted the resident was found by staff outside of the facility building on the asphalt of the driveway. The resident had fallen out of her wheelchair and had injuries to her face. The incident report noted Emergency Medical System (EMS) was called and Resident #1 was transported to the hospital. The hospital emergency room history and physical dated 5/6/2018 was reviewed. Resident #1 was diagnosed and treated for [REDACTED]. The CT (computed tomography) scan revealed acute bilateral nasal bone fractures with soft tissue injury. An x-ray of Resident #1 hands and knees were negative for fractures. Resident #1 was observed on 5/8/2018 at 6:58 PM. She was sitting in her wheelchair and had bruising to her face, sutures above her left eye and abrasions to her bilateral knees and face. A wanderguard was on her right ankle. Resident #1 was interviewed on 5/8/2018 at 6:58 PM. She was confused and was unable to relate how she received her injuries. Nurse #1 was interviewed on 5/8/2018 at 9:18 PM. Nurse #1 related she was very familiar with Resident #1 and had been assigned to her on the day of her fall. Nurse #1 reported Resident #1 had been sleeping in her wheelchair beside the medication cart on 5/6/2018. She reported that Resident #1 required staff to keep track of her whereabouts, but Nurse #1 had not noticed wandering or elopement behaviors. Nurse #1 reported she had left the medication cart to retrieve supplies and stopped to speak to the nursing supervisor on her way back to the cart. Nurse #1 guessed she was gone for no more than 10 minutes. Nurse #1 went on to describe receiving an overhead page calling for nursing staff to the front doors. She and the nursing supervisor arrived at the front doors to see Resident #1 on the ground outside the facility. Resident #1 ' s wheelchair was sitting on the sidewalk and Resident #1 was face down on the parking lot asphalt pavement. Nurse #1 reported she returned inside the building to call EMS, the DON, the administrator, the family member and the physician. EMS arrived and transported Resident #1 to the hospital for evaluation. The facility ' s front doors and the outside entrance were observed on 5/9/2018 at 3:37 PM. Nurse #1 identified the area on the pavement of the facility ' s parking lot where Resident #1 was found on 05/06/18 and the location of her wheelchair on the sidewalk. The Maintenance Director measured the distance of 29 feet from the doors to the pavement where Resident #1 had fallen outside of the facility while unsupervised. Nursing assistant (NA) #1 was interviewed on 5/9/2018 at 9:33 AM. She reported she had been notified that Resident #1 had fallen, but was not told her location. NA #1 was not assigned to Resident #1, but was familiar with Resident #1 and had checked her wanderguard prior to the hospitalization in (MONTH) (YEAR). NA #1 reported she went around the building looking for her because she was not told where she fell . The Medical Records staff was interviewed on 5/9/2018 at 9:47 AM. She reported she was working on 5/6/2018 and was in the front conference room. The Medical Records staff reported she heard the overhead page for staff to come to the front and she went to the lobby and observed Resident #1 outside on the parking lot pavement. Medical Records reported that Resident #1 had attempted to open doors in the past and made statements that she wanted to go home, but she had not shown those types of behaviors since she was readmitted from the hospital in (MONTH) (YEAR). The Activity Aide (AA) was interviewed on 5/9/2018 at 9:57 AM. The AA reported that she had been assigned to the receptionist area which was beside the front doors in the facility on 5/6/2018. The AA reported a resident had approached her asking for a snack and she took the resident back to the activities room and provided her with a snack and turned on the TV for the resident. The AA guessed she was gone from the front desk for less than 10 minutes. The AA then reported as she headed towards the front desk, a visitor came into the building and said a resident had fallen outside. The AA reported she used the phone to call staff to the front STAT (without delay) and went around the corner where she could see the resident on the ground outside of the building. A visitor was beside Resident #1. The AA reported that staff arrived very quickly to the outside of the building. The AA concluded by reporting she had not seen Resident #1 in the hall or in the front lobby when the AA left the front desk, and no alarms were sounding when she returned to the front desk. Nurse #2 was interviewed on 5/9/2018 at 11:55 AM. She reported she completed the elopement risk assessments for residents and specifically the assessment for Resident #1 completed on 5/4/2018. Nurse #2 reported that she had not observed elopement behaviors from Resident#1 and no one had reported that Resident #1 was exhibiting any wandering or exit-seeking behaviors to her, so on 5/4/2018 the nursing staff had determined the resident was not an elopement risk. The acting Director of Nursing (DON) was interviewed on 5/9/2018 at 11:58 AM. She reported the nursing staff had discussed the wanderguard placement on Resident #1 when she returned from the hospital on [DATE]. They decided to place a wanderguard on Resident #1 because she had a wanderguard and exit-seeking behaviors prior to her hospitalization , but three days later another elopement risk assessment was completed and because she was not getting out of bed, so the facility removed the wanderguard. The DON continued to explain that a chart audit had been completed on 4/9/2018 and staff found the wanderguard had not been discontinued, so another order had been written and the wanderguard was discontinued. The DON reported it was her expectation that wandering behaviors were reported to the nursing management staff and addressed with risk assessments and the staff at the front door monitored residents and reported elopement behaviors to the nursing management staff. An interview with Nurse #3 was conducted on 5/9/2018 at 12:25 PM. She reported she had completed the elopement risk assessment dated [DATE]. She related Resident #1 was refusing to get out of bed at that time. Nurse #3 reported that Resident #1 had elopement behaviors prior to her readmission on 3/27/2018 and would ask for a ride home and wandered the facility in her wheelchair. Nurse #3 further reported that she had completed the elopement risk assessment on 5/1/2018 and she had not been told the resident was wandering in the facility or had combative behaviors. NA #2 was interviewed on 5/9/2018 at 2:01 PM. NA#2 reported she was a restorative aide and was responsible for checking the wanderguards every day. NA #2 reported that Resident #1 had a wanderguard in the past, but it was removed when she was sent to the hospital and when she returned on 3/27/2018. NA #2 had asked Nurse #2 if Resident #1 would have a wanderguard applied and she was told no and as far as she was aware, Resident #1 did not have a wanderguard on after she was readmitted on [DATE]. An interview was conducted with NA #4 on 5/9/2018 at 2:26 PM and she reported she had to track down the resident in the past, and had found her in the nursing office. NA #4 was not certain of the date of the incident or if it was before or after the hospitalization , and could not recall if she informed nursing staff the resident was wandering. The weather on 5/6/2018 per accuweather.com was partly cloudy without rain and a high of 82 degrees. Resident #1 was dressed in socks, shoes, pants, a blouse and a sweater, per an interview with Nurse #1 on 5/9/2018 at 2:28 PM. NA #1 was interviewed again on 5/9/2018 at 2:22 PM. She reported that on Thursday 5/3/2018 she observed Resident #1 attempting to open the front doors. NA #1 reported that she had redirected Resident #1 and called the nursing office to report to Nurse #2 on that date. The Administrator, DON and facility consultant were notified of Immediate Jeopardy on 5/9/2018 at 5:20 PM. Date: 05/09/2018 PROBLEM IDENTIFIED: Resident #1 exited the facility on 5/6/2018 at approximately 11:15AM through the front door of the facility; resident was observed by another resident family member #1 who was visiting the facility. Family member #1 notified the facility Activity Assistant #1 on 5/6/2018 at 11:15am, who was working in the capacity of the receptionist (receptionist #1) on 5/6/2018, immediately after observing the resident outside the front door. On 5/9/2018 Interim Director of Nursing (DON) contacted family member #1 via phone, family member #1 stated, she witnessed resident #1 exiting the facility through the front door. Resident #1 was observed by family member #1 on 5/6/2018 at 11:15am on the ground outside the front door. Resident #1 sustained a nose fracture and discoloration above the eye that required medical intervention at the local hospital emergency department. ROOT CAUSE ANALYSIS - THE PR[NAME]ESSES THAT LEAD TO THE ALLEGED DEFICIENCY CITED Family member #1 notified the facility Activity Assistant #1 on 5/6/2018 at 11:15am, who was working in the capacity of the receptionist on 5/6/2018, immediately after observing the resident outside the front door. Resident #1 exited the facility through the front door, family member #1 witnessed resident #1 exiting the facility, through the facility main entrance door, while visiting the facility on 5/6/2018 at 11:15AM. Resident #1 was exercising her rights to go outside the facility. The facility did not provide supervision for resident #1 while outside the facility on 5/6/2018. Most recent Minimum Data set MDS 3.0 assessment for resident #1 completed on 4/3/2018 indicates resident can make self-understood and usually understand others. Resident #1 is not deemed incompetent, and when asked by Registered nurse #1 on 5/6/2018, resident stated she wanted to sit outside. Interview with the Interim Director of Nursing conducted on 5/9/2018 by the Company Chief Clinical officer indicates that resident is able to choose her clothes to wear, time to be up or go back to bed and her where about, even though resident has episodes of behaviors as well. Resident #1 stated she wanted to go outside for a short while. Elopement risk assessment completed on 05/04/2018 indicates resident was not at risk for elopement hence, the facility maintained resident#1 rights to go and come as she is pleased based on the assessment and per resident ' s bill of rights, however the facility did not monitor resident #1 while outside the facility. Resident #1 most recent elopement risk assessment completed on 5/4/2018. The assessment indicates, resident #1 was not at risk for elopement. This conclusion was set forth based on resident history of wandering safely in the facility since the last assessment, contrary to such attempts before the previous assessment. On 5/6/2018 at 11:15am the receptionist #1 who was on duty walked away from the front desk to obtain snack for a resident. Receptionist #1 left the unlocked front door unattended that resulted resident #1 exiting the facility. Based on the location of where resident was observed in relation to the location of wheel chair it is concluded that resident slid out of the wheel chair to the ground while on the front porch. Receptionist #1 will contact a licensed nurse who care and familiar with the resident who is requesting to go outside to validate whether resident is safe to go outside or not, if resident is not safe to go outside alone Receptionist #1 will not allow the resident to go outside unsupervised. If resident desire to be outside, the facility will provide necessary supervision to prevent accident while outside and allow resident #1 to exercise her rights effective 5/9/2018. THE PR[NAME]EDURE FOR IMPLEMENTION THE ACCEPTABLE PLAN OF CORRECTION Staff on duty was alerted by Activity Assistant #1 via overhead code green announcement that resident #1 had exited the facility via the front door and was noted on the ground. Resident #1 head to toe assessment was completed by Registered nurse #1, Licensed Nurse #1, & Licensed Nurse #2 while outside the facility on 5/6/2018. Resident #1 was sent to the emergency roiagnom on [DATE] at approximately 11:15am for an evaluation and treatment via the County Emergency Medical Services. Resident returned to the facility on [DATE] at 7:25pm. The intervention implemented for resident #1 included placement of a wander control bracelet, care plan revision to include intervention such as keep resident in common areas as appropriate. Resident #1 care plan also included intervention for staff to be observant and notify the nurse when they see resident #1 pushing on the door or verbalizing that she wanted to go home or exhibiting any other exit seeking behaviors. Resident #1 care plan also include the intervention for staff and/or family member will supervise the resident while the resident is exercising her rights to be outside effective 5/9/2018, and monitoring the front door by a designated staff member while the front door is unlocked during the hours from 8:00AM to 5:00pm, effective 5/9/2018 and indefinitely. If the staff member who monitor the front door is not available for any reason, and for any duration of time the door will be locked. The attending physician was notified on 5/6/2017 at 11:50AM and Responsible Party was also notified on 5/6/2017 at 11:35AM. 6 of 7 other exit doors are secured with the keypad that requires secret code to open the door. Facility plant operation coordinator checked all exit doors for proper closure and functioning of the key pads on 5/6/2018. All doors are functioning properly. Facility plant operation coordinator change the codes for all exit doors monthly. Four of seven exit doors, had codes changed to an anonymous code, only known to the Administrator, and Facility Plant operation coordinator, on 5/9/2017. IDENTIFICATION OF OTHER RESIDENTS WITH A POTENTIAL TO BE AFFECTED 100% of Elopement risk assessments for all current residents completed on 05/09/2018, by the Interim Director of Nursing, Unit Coordinator #1, Licensed nurse #3 and Licensed nurse #1 to identify any other residents who might be at risk for exit seeking behaviors. Seven other residents who were previously identified to be at risk for elopement, re-identified during this assessment, and one new resident was also identified to be at risk. Elopement books revised and placed at the front desk, and at each nurse ' s station by Unit Coordinator #2 on 5/9/2018. These books contain a list of residents with exit seeking behaviors, their pictures and resident ' s descriptions. These Elopement books were reviewed by the facility Regional Nurse Consultant #2 on 5/09/2018 to validate all noted residents who are at risk are included. The Elopement books are located in a place accessible to all staff for easy identification of elopement risk residents (at the front desk, and at each nurse ' s station). Unit coordinator #2 will review and revise elopement books at least monthly and as needed, such as when a new resident is added or removed from elopement management program. Effective 5/9/2018, if a resident expressed a desire to go outside to the receptionist #1 or any other employee, the receptionist and/or the employee will contact a licensed nurse who cares and is familiar with the resident who is requesting to go outside to validate whether resident is safe to go outside or not, if resident is not safe to go outside alone Receptionist #1 will not allow the resident to go outside unsupervised. If resident desire to be outside, the facility will provide necessary supervision to prevent accident while outside and allow the resident to exercise their rights effective 5/9/2018. 100% of all exit doors were audited by the facility Plant Operation Coordinator on 5/9/2018 to validate all exit doors are secured properly. All exit doors are functioning properly. Findings of this audit is documented on facility floor plan titled exit doors audit form located in the facility Compliance binder IDENTIFICATION OF OTHER RESIDENTS WITH A POTENTIAL TO BE AFFECTED Effective 5/9/2018, and moving forward, licensed nurses will complete elopement risk assessments for all residents on admission/re-admission, quarterly, with any significant changes of resident ' s condition, and/or whenever a resident is noted to exhibit exit seeking behaviors/attempts. Any noted concerns will be addressed and corrected by licensed nurses immediately; interventions will be implemented and resident ' s care plan will be revised and updated immediately by licensed nurses. Direct care staff will be notified of new interventions put forth by a licensed nurse through resident ' s care guide which are located in electronic nursing aide documentation software at each unit. Appropriate intervention to ensure residents who are cognitively impaired receive necessary supervision to prevent accidents while outside the facility will also be included in residents ' care plan effective 5/9/2018. Effective 5/9/2018, the center assigned an employee to monitor the front door, while the front door is unlocked during the hours from 8:00am to 5:00pm daily continuously. If the employee is not available to monitor the front door for any reason, or any duration of time the front door will be locked by the Receptionist or designated person using a key code effective 5/9/2018. Visitors will ring a bell to be assisted by staff on duty to open the door. Receptionist #1 or designated staff member who monitor the front door will contact a licensed nurse who is familiar with the resident requesting to go outside to validate whether the resident is safe to go outside or not, if resident is not safe to go outside alone Receptionist #1 or designated staff member who monitor the front door or will not allow the resident to go outside unsupervised. If any resident who is cognitively impaired desire to be outside, the facility will provide necessary supervision to prevent accident while outside and allow the resident to exercise their rights effective 5/9/2018. Effective 5/9/2018, the center interdisciplinary team, which includes Interim Director of Nursing, MDS nurse #1, Unit coordinator #1, Unit Coordinator #2, Social worker #1, and Activity Coordinator #1, initiated a process for reviewing all new admission/re-admissions, Monday through Friday for any prior history of aggressive behaviors, elopement, physical aggression and/or attempts to exit the facility. Any identified issues will be addressed promptly and plan of care developed as appropriate to include supervision necessary to prevent accident while resident is outside the facility. Effective 5/9/2018, week end RN supervisor and/or designated licensed nurse will review all new admission/re-admissions every Saturday & Sunday for any prior history of aggressive behaviors, elopement, physical aggression and/or attempts to exit the facility. Any identified issues will be addressed promptly and plan of care developed as appropriate. The Director of Nursing will review and sign for accuracy, of the elopement books daily (Monday through Friday) and week end RN supervisor on Saturday and Sundays, the Administrator will review and sign weekly for the previous week for next 6 months. The review will validate the presence of resident ' s profile, pictures, appropriate intervention and accessibility of the wander guard books. Any negative findings will be addressed immediately and reported to the monthly QAPI committee meeting by the Director of Nursing. Effective 5/9/2018 Residents at risk for elopement will be identified using elopement books located at the front desk and at each nurse ' s station. Elopement Books, contain pictures and detailed descriptions of all residents listed as elopement risks. Effective 5/9/2018 Interim Director of Nursing, Unit coordinator #1, Unit Coordinator #2, or designated staff will review and update the Elopement books with changes as they are identified for elopement via risk assessments. Elopement books are in a location accessible to all staff for easy identification of elopement risk residents. On 5/9/2018, The Executive Director educated the Receptionist #1 not leaving the desk unattended while the door is unlocked during the daytime hours of 8AM to 5PM. Receptionist was also educated to lock the front door if the receptionist leaves the front desk without a relief for any reason, effective 5/9/2018. A sign in/out sheet was implemented by the Regional Clinical Consultant #2 to ensure the reception desk is attended when doors are unlocked (8:00am-5:00pm). Receptionist #1 or designated staff member who monitor the front door will contact a licensed nurse who is familiar with the resident requesting to go outside to validate whether the resident is safe to go outside or not, if resident is not safe to go outside alone Receptionist #1 or designated staff member who monitor the front door or will not allow the resident to go outside unsupervised. If any resident who is cognitively impaired desire to be outside, the facility will provide necessary supervision to prevent accident while outside and allow the resident to exercise their rights effective 5/9/2018. Executive Director, and/or Interim Director of Nursing, conducted re-education for current scheduled staff, full time, part time and as needed employee for all departments on 5/9/2018, this education included checking Wander Control Transponder (bracelet) placement every shift, how to respond to exit door alarms, identification of resident who are at risk for elopement, and locking of the front door while the receptionist is away from the front desk. The education also included on how to identify resident who are safe to go outside unsupervised by contacting the licensed nurse who is familiar with the resident requesting to go outside and validate whether the resident is safe to go outside or not, the education emphasized that, if resident is not safe to go outside alone Receptionist #1 or designated staff member who monitor the front door or will not allow the resident to go outside unsupervised the. Any staff not re-educated by 5/9/18 will not be allowed to work until educated on this requirement. Effective 5/9/2018 Education on the facility elopement policy and procedure and responding to door alarms is added on new hires orientation education for all new facility employees. This education will also be provided annually for all staff. THE MONITORING PR[NAME]EDURE TO ENSURE THAT THE PLAN OF CORRECTION IS EFFECTIVE Effective 5/09/2018 Business office Manager will monitor the compliance with the receptionist monitoring of the front door by validating sign up log Monday through Friday for ten days then weekly for four weeks than monthly for three months or until the pattern of compliance is maintained. Effective 5/9/2018, Facility Executive Director will monitor compliance with checking of the exit doors conducted by the facility Plant operation coordinator or designated staff Monday through Friday for ten days then weekly for four weeks than monthly for three months or until the pattern of compliance is maintained. Effective 5/09/2018 the Interim Director of Nursing will monitor the accuracy of the elopement books, and completion of elopement risk assessment on admission, re-admission and quarterly Monday through Friday for seven days then weekly for four weeks than monthly for three months or until the pattern of compliance is maintained. Effective 5/9/2018, Executive Director and/or Interim Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for three months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. THE TITLE OF THE PERSON RESPONSIBLE FOR THE IMPLEMENTATION OF ACCEPTABLE PLAN OF CORRECTION Effective 5/9/2018 the facility executive Director and the interim Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. The Credible Allegation of Immediate Jeopardy Removal was completed by the facility on 5/10/2018 at 9:47 PM. The corrective action plan was verified on 5/10/2018 and 5/11/2018. Elopement Risk Assessments were completed on all residents present in the facility on 5/9/2018 by the DON, and licensed staff, and seven resident who were identified prior, plus one new resident were identified as elopement risks. The elopement book was observed to be at the front desk and included a picture and demographics of the residents currently identified at risk for elopement. The staff in-services conducted 5/9-10/2018 were reviewed and included: the facility policy on elopement, the elopement book and the location, the receptionist desk to be staffed 7 days per week, 8:00 AM to 5:00 PM and the front doors will be locked at 5:00 PM. The front doors were not to be left unattended during the day from 8:00 AM to 5:00 PM. The attendance records confirmed that all staff had been in-serviced. Random staff interviews were conducted on 5/10/2018 starting at 2:00 PM and ending at 4:30 PM, and on 5/11/2018 starting at 4:45 AM and ending at 10:32 AM. All staff members could describe the topics covered during the in-service on elopement. The daily Exit door functioning monitoring records from (MONTH) (YEAR) to 5/10/2018 were reviewed and complete. The function of all exits were observed on 5/10/2018, as well as a wanderguard demonstration. The DON was interviewed on 5/11/2018 at 10:52 AM. She reported that all residents had an elopement risk assessment completed on 5/10/2018 and one resident was identified with behaviors similar to Resident #1 and a wanderguard had been applied for the resident ' s safety. The audits of residents were reviewed and found to be completed.

Based on record review and staff interviews the facility failed to provide supervision for one (Resident #131) of three sampled residents with exit seeking behaviors. While on every fifteen minute checks, Resident #131 exited the facility in his wheelchair into the parking lot, fell out of the wheelchair onto the pavement and sustained minor scrapes to his back. Resident #131 was in the middle of the turn in area of the parking lot with a likelihood for potential serious bodily injury. For example #2 (Resident #55) the facility failed to ensure one of 21 residents with side rails did not have a gap between the mattress and side rail. For example #3, the facility failed to cover exposed metal screws on a handrail on one of 4 halls. The Immediate Jeopardy began on 3/20/16 when Resident #131 exited the facility unsupervised and a visitor reported to a nursing staff member he was outside on the front porch. Approximately ten minutes later staff checked on the resident and found him 144 feet from the front porch, at the incline of the parking lot, leading to the turn in from the main road. Resident #131 was out of the wheelchair, sitting with his legs straight out in the middle of the parking lot. The Immediate Jeopardy was removed on 3/31/16 when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity of no actual harm and potential for more than minimal harm that is not immediate jeopardy (D) due to two other examples under F323, to ensure systems of monitoring are in place and 100% of employee training. The findings included: 1. Resident #131 was admitted to facility on 1/15/16 with [DIAGNOSES REDACTED]. Elopement Risk assessment dated [DATE] indicated the resident was not cognitively impaired with poor decision making skills, had no history of elopement, did not wander in building. This assessment included the following risk factors: He had a communication impairment, expressed a desire to go home and was recently admitted and not accepting the situation. This assessment conclusion was Resident is not at risk for elopement/wandering at this time. The Admission Minimum Data Set (MDS), assessment dated [DATE] indicated Resident #131 had a Brief Interview Mental Status (BIMS) of 3 (severe impairment in memory and mental functioning abilities). The MDS assessed Resident #131 as having behaviors of verbal and physical aggression towards others and no wandering behaviors. This MDS indicated extensive assistance by staff was required with all activities of daily living, he was not ambulatory, and required one person assist for locomotion. Review of the monthly orders for March 2016 included one antipsychotic medication, Lexapro 10 milligrams (mg) every day for depression. The nurse ' s note dated 3/19/16 indicated Resident #131 at 2:39 AM was observed on the floor and had fallen out of bed. When staff asked him where he was going he stated I am getting out of here I am going home . The nurse ' s note dated 3/19/16 at 6:16 AM revealed the fire alarm was sounding on side B. Resident #131 was observed touching the alarm. Resident #131 was placed on every 15 minute checks by nursing staff. Review of the flowsheets with documentation of every 15 minute checks of Resident #131 by staff began on 3/19/16 at 6:00 PM. These checks were initiated due to the resident pulling the fire alarm. The nurse or nurse ' s aide signed with their initials at a timeframe. A line was drawn from that timeframe down the list of every 15 minutes for the next 2 to 3 hours the resident was to be checked. This flowsheet did not indicate where the resident was located during those checks. The nurse ' s note dated 3/20/16 at 6:55 PM, written by Nurse #2, revealed the following: · A nurse ' s aide passed Resident (#131) in the hallway at 5:30 PM and told the resident that dinner was coming and to go to his room to eat. · At 5:45 PM a family member of another resident informed dining room staff that they saw this Resident (#131) outside of facility on the porch. Dining room nurse ' s aide informed this nurse of the comment. Hall 4 nurse outside at this time to get Resident (#131) approximately 5:40 PM. This nurse accompanied hall 4 nurse. Observed resident in parking lot, on ground in front of wheelchair with chair alarm sounding. Full assessment completed at this time. Redness noted to back. Impressions from rocks on resident hands. No other areas noted . When asked what he was doing resident stated Getting out of here. DON (Director of Nursing) gave instructions to check placement of wander guard every 15 minutes. If resident removes wander guard, place call to family to have them sit with him. Hall 4 nurse left message for doctor and for family to call the facility for details about incident. The family called back at 7:15 PM and was made aware. Resident (#131) continued on every 15 minute checks. Addendum to note: Resident also stated to nurse ' I was going to drop my men off. ' The wander guard placement check was located on the Treatment Administration Record (TAR). The bracelet was applied to Resident #131 on 3/20/16 on 3-11 shift. The TAR documented it was checked every shift. The nurse ' s note dated 3/21/16 at 10:52 PM revealed Resident #131 was observed by another staff member between the first set of doors and second set of doors at the front facility entrance. The wander guard was in place and the alarm was sounding. Resident #131 was holding on to the door handle refusing to come in the facility with the staff member. Resident #131 was brought back to B side several times and continued to wander around facility in his wheel chair. The responsible party was called to come sit with the resident to prevent him from trying to exit the facility. Mental health Nurse Practioner was notified and gave orders to make medication changes. The care plan was updated 3/22/16 for exit seeking behavior with interventions that included to place the resident in area where frequent observation was possible, wander guard placed on his left ankle, alert staff to his wandering behavior, provide diversional activities, if wandering away from unit, instruct staff to monitor him, and persuade him to come back, 30 minute checks of his whereabouts throughout the day for his location and safety, note which exits he favors for elopement and monitor and document his behavior. Review of a physician ' s progress note dated 3/23/16 revealed Resident #131 did not recall going outside into the parking lot. The every 15 minute checks continued as evidenced by the documentation on the flowsheet until 3/24/16 at 7:00 AM at which time it was changed to every 30 minutes. Night shift nurses were to check the function of the wander guard. Review of the documentation on this flowsheet revealed the wander guard bracelet was applied on Resident #131 on 3/20/16 at 7:00 PM. Resident #131 had documentation his was checked from 3/20/16 to 3/23/16. There was a missing check on 3/24/16. The checks were documented again on 3/25/16 to 3/29/16. Review of the Wander guard Log book revealed other residents with wander guard bracelets had missing documentation that checks were performed each night. Interview with Nurse ' s Aide (NA) #, who had been informed about Resident #131 being outside, was conducted on 3/30/16 at 8:54 AM. NA #1 explained she was in the dining room that evening setting up trays and drinks. The care taker for another resident, told her the resident (#131) was on the front porch. NA#1 called the nurse at the nursing station for both halls from a phone in the dining room. Nurse #2 answered, she was not the nurse for Resident #131. Resident #131 resided on hall 4. The nurse for hall 4 was Nurse #3. This NA asked Nurse #2 to check on the resident, he was outside. Further interview revealed Nurse #2 told this NA she would get Nurse #3 and check on the resident. NA#1 explained she was the only person in the dining room and could not leave. She saw both nurses within minutes after the phone call going past the dining room towards the porch. Interview on 3/30/16 at 9:25 AM with Nurse #2 revealed she was in the office charting and was informed by NA#1 a family member had just come in, described a man they thought was a resident sitting outside. She was not the nurse on Resident #131 ' s hall. Nurse #2 got Nurse #3who was on Resident #131 ' s hall. Continued interview revealed both nurses went outside at about 5:40 PM. Nurse #2 explained Resident #131 was off the sidewalk, at the bend of the parking lot. Resident #131was out of the wheel chair, like he slid out of the chair. He was directly in front of his chair, legs out straight, sitting up. He was able to get back to the chair with assistance of two staff. Upon assessment, he had redness on his back and he was leaning on his left side. When asked what he was doing, He said he was getting out of here, had to pick up his boys. Interview on 3/30/16 at 10:03 am with the facility nurse consultant revealed the wander guards have an expiration date and lot number. The wander guards are logged into a book by the ADON with the expiration date and lot number. This book was in place and updated on 3/10/16. Interview with Nurse #3 on 3/30/16 at 10:38 AM revealed on 3/20/16 Resident #131 was in the hallway at 5:30 PM. Nurse #3 was doing her 6:00 PM medication pass. This nurse was asked what time she last saw Resident #131 she stated it was about 5:50 PM and he was at the doorway to his room. A nurse (Nurse #2) had called her and told her he was outside. Continued interview revealed she received that call about 5:35 PM and they went outside about 5:40 PM. Further explanation by Nurse #3 revealed Resident #131 was right out in parking lot and slid out of the wheel chair. Interview with Nurse #4 on 3/30/16 at 10:56 AM revealed she worked the 3-11 shift on 3/21/16. Nurse #4 explained she had provided care for Resident #131 and he had behaviors and attempted to exit the building and did exit one time. Nurse #4 explained Resident #131 had attempted to exit the facility after the wander guard had been applied. Nurse #4 explained on 3/21/16, he was wandering around the building in his wheel chair. He got between two sets of doors, and the alarm sounded. A NA saw him, tried to get him back in but he resisted. The resident refused to let go (of the door) and grabbed another resident ' s wheel chair. This occurred around 7:00 PM. The aide was leaving for the day. Interventions that were tried by staff to redirect him included offer other activities/food. He had refused diversional activities. An order was obtained from the Nurse Practioner at Mental Health for Ativan (an anti-anxiety medication). Further interview revealed the Ativan helped decrease his behaviors. Interview with NA #3 on 3/30/16 at 12:07 PM revealed she had worked with Resident #131 on 3/20/16 on the 3-ll shift. Interview with NA#2 revealed she was not aware of any behaviors for resident #131 and she had not heard him make any comments before that day about leaving. She further explained he did not talk much anyway. NA #2 explained on the evening of 3/20/16 she had observed Resident #131 in the hallway. She had told him to go to his room, it was time for supper. NA#2 was passing supper trays out when she saw him. Further interview revealed she did not see if he went into his room. He would usually go to his room when directed to do so. The time she saw him was about 5:30 PM. She continued down the hall away from his room, and he was rolling up the hall. NA#2 heard a lady telling a nurse he was outside facility. NA#2 further explained she went outside with her nurse (Nurse #3) and another nurse (Nurse #2). This NA gave a visual demonstration outside where Resident #131 was found in the parking lot. Continued interview with NA#2 revealed it was still light outside when she went outside to get the resident. She was not aware of what time it was when she went outside. The nurses got the resident up and back into the wheelchair. She saw the resident had been sitting on the driveway with the wheelchair behind him. After he came back inside, she assisted him to bed. The distance was measured by the maintenance director and was found to be 144 feet from the front porch to the area in the parking lot where Resident #131 was found. This was about 75 feet from the initial entrance from the main road into the facility parking lot. It was not in view of the staff unless they were in a room looking out the window facing the parking lot. Interview with the Maintenance Director on 3/31/16 at 12:15 PM revealed the doors would alarm if a resident with a wander guard bracelet went through the doors when opened by a visitor. If the door was already open when the resident approached near the door, the alarm would sound, but the resident could continue through the first door at the front entrance. Interview with the Director of Nursing (DON) on 3/30/16 at 12:30 PM revealed Resident #131 was not very conversant. He had flat affect, would not really respond verbally. She was not aware of any remarks the resident had made prior to 3/19/16 about leaving. Interview with nurse #1 on 3/31/16 at 10:56 AM revealed she had completed the Elopement assessment dated [DATE]. Nurse #1 explained Resident #131 was cognitively impaired and an error was made in typing her response. She further explained the resident had confusion, was unable to answer more than one word responses and those were inaccurate at times. Interview with the Director of Nursing (DON) on 3/30/16 at 12:30 PM revealed Resident #131 was not very conversant. He had flat affect, would not really respond verbally. She was not aware of any remarks the resident had made prior to 3/19/16 about leaving. Interviews with physical therapists #1 and 2 on 3/31/16 at 9:22 AM revealed Resident #131 had varied levels of participation with therapy. He had the ability to walk 100 feet if he wanted to do so. He propelled the wheel chair with both hands and mostly one foot, but could use the other foot. He had been depressed, and had not mentioned about going home. On his bad days, he needed assistance eating, but on his good days, he was able to participate in therapy very well. Interview with the Administrator on 03/31/2016 3:20:34 PM revealed her expectations of staff would include notify charge nurse of behaviors, do a risk assessment, and do monitoring. If a resident was actively exit seeking, put a wander guard on the resident. She would expect staff to update the notebooks with resident info, update care plan as needed and continue to assess/review that resident. During the Administrator interview, she explained Resident #131 must have got it in his mind he wanted to go home. A church group was here that evening. As the group was leaving, went out the doors with them. In her investigation, the visitor was a sitter for a resident in the facility. She did not sign in, and they did not have a time she entered the facility. This sitter knew NA #1 and told her about a resident outside. Interview with NA #1 on 4/1/16 at 8:45 AM revealed the sitter came each day between 5:00 and 5:30 PM. Interview with NA #3 on 4/1/16 at 9:00 AM revealed Resident #131 had pushed on the door last Thursday (3/24/16) a couple of times. He had said he wanted to get his truck. The administrator was informed of Immediate Jeopardy on 3/30/16 at 4:10 PM. The facility provided credible allegation of compliance on 3/31/16 at 4:30 PM. Corrective action for Resident #131: Resident #131 was returned safely to the facility from the end of the sidewalk attached to the building adjacent to the parking lot. by Nurse #1 & Nurse #2. Upon his return a complete nursing skin assessment was conducted. There was redness noted to his back and impressions from rocks on resident hands no other areas noted, resident denies any pain or discomforts at that time. The facility investigation revealed that resident #131 was observed by nursing assistant #1 at 5:30PM sitting in his wheel chair on the hallway close to the dining room. The intervention implemented on 3/20/2016 for resident #131 was placement of a wanderguard to his left ankle and 15 minute checks by staff as to resident #131 location x 72 hours, then 30 minutes checks afterward until 3/31/2016 as precautionary measure after placement of the wander guard. Staff was alerted to resident #131's exiting the facility, the attending MD and RP were notified on 3/20/2016. Resident #131 Elopement Risk Assessment was updated on 3/21/2016 and Care Plan were updated on 3/20/2016. On 03/21/2016 Resident #131 was observed by another staff member #2 on his wheel chair between first set of doors and the exit doors, wanderguard was in place and alarm activated, staff member #2 redirected resident away from the door. Corrective action for other residents that may be affected: Elopement risk assessment for all Current residents were completed on 03/20/2015, 03/21/2016, 03/22/2016, 03/23/2016, 03/24/2015 & 03/25/2016 by the Director of Nursing and the Assistant Director of nursing to identify any other residents who might be at risk for exit seeking behavior. Residents identified as having exit seeking behaviors have up to date Care plans in place. Elopement book' located at the front desk that contains list of resident with exit seeking behaviors, their pictures and resident's description was updated and revised by the Assistant Director of Nursing to include resident #131 information on 03/25/2016. All doors were checked for proper closure and locking by Maintenance Supervisor on 03/24/2016, Electric and Life safety System (C.T.E, INC) inspected the magnetic door locks system on the exterior doors on 3/24/2016. The company concluded all doors functioned properly and no problems were found. System(s) put in place to prevent reoccurrence: Moving forward elopement risk assessments will be conducted for all residents on admission/re-admission, then monthly for two more months, to determine resident's elopement risk baseline on admission/re-admission and capture any changes for two more months. Then elopement assessment will be completed quarterly and/or with any significant changes of resident's condition. Any noted concerns will be addressed and corrected by licensed nurses immediately, appropriate intervention will be implemented and resident's care plan will be revised and updated with appropriate interventions Two additional Elopement Books, which contain pictures and detailed descriptions of all residents listed as elopement risks, have been placed at every unit a nd the front desk on 3/31/2016. Nurse Managers will review and update binders with changes as they are identified on elopement risk assessments. Nursing staff is checking for proper placement of Wander guard bracelets every shift and recording findings on the residents' treatment administration record. Functioning of bracelets of all residents wearing wanderguard bracelets are also checked and logged daily on wanderguard function tracking form by the Restorative Aides effective 3/31/2016. Restorative aide will also monitor expiration dates of all wanderguards in use effective 3/31/2016 and report findings to the Administrator or designee immediately. Wanderguard expiration is included in wanderguard function tracking form Facility will follow manufacturer recommendation on placement of wanderguard. Effectively 3/31/3016 Maintenance Personnel or Manager on duty will check and log the proper closure and locking of all exit doors daily on exit doors function check form for 30 days, then Weekly afterward. Any noted concerns will be addressed and corrected immediately. Standard of care meetings will be conducted weekly to discuss residents at risk for elopement to ensure intervention in place are appropriate. All new admits/re-admits regardless of their elopement risk will be reviewed at standard of care meeting weekly for four weeks for wandering and exit seeking behaviors. Those residents' elopement risk will be reviewed to identify if there are any changes in comparison to a prior assessment. If changes are noted intervention will be implemented promptly to mitigate the risk. Regional Clinical Director # 1& # 2 re-educated The Administrator and the Director of nursing on revised facility elopement process as identified above on 3/30/2016. The Director of Nursing initiated in-service education for all staff on 3/30/2016, to include early identification of changes of condition, particularly related to exit seeking behaviors . 100% of all current staff reeducated on the facility elopement policy and procedure by 03/31/2016. Any staff not educated by 03/31/2016 will not allowed to work until educated on this requirement. Education on the facility elopement policy and procedure will be added on new hires ' orientation education for all new facility employees. This education will also be provided annually for all staff. This in service education include how to identify exit seeking behaviors, new revised facility reporting protocol including reporting repeated verbalization of intent to go home to the charge nurse and what to do for those residents who have shown exit seeking behaviors. Validation of the credible allegation of compliance was conducted on 4/1/16. Records reviewed of Residents #131, 55, 19 and 98 revealed elopement risk assessments and care plans were updated. Observations of residents #131, 55, 19 and 98 revealed wander guard bracelets were on the residents. Wander guard placement checks were documented as done on the TARs by nurses on each shift. The Restorative NA flowsheets for wander guard function testing was completed. Interviews with facility staff revealed inservices had been conducted and verbalized understanding of the content. Review of the Maintenance Director ' s log for function of the doors alarm system revealed checks were completed daily. 2. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an admission, dated 3/2/16 indicated he had moderate impairment with memory. Hus Brief Interview Memory Status (BIMS) was a 10. This MDS assessed Resident #55 as requiring extensive assistance with one person assistance for activities of daily living. Resident #55 was ambulatory with limited assistance of one person, and required supervision with eating. The care plan dated 3/9/16 for a problem of falls and exit seeking behaviors indicated he was at risk due to poor safety awareness, seizure disorder and impulsive behaviors. Interventions for this problem included resident was to ask for assist when reaching for objects that are out of his reach, keep call bell and items of frequent use in his reach while in room, wander guard to left ankle for safety, seat belt to wheelchair, Dycem to the wheel chair and monitor changes in condition that may warrant increased supervision/assistance and notify the physician. The care plan addressed a problem of at risk for injury related to seizure disorder and interventions included to protect him from injury during witnessed seizures. Review of a physician ' s note dated 3/24/16 indicated Resident #55 had seizure disorder secondary to [DIAGNOSES REDACTED]. The progress note indicated he had frequent seizures that were fairly short lived, he had no aura and a short post ictal phase. The resident was generally fairly lethargic, however this was his baseline. This note did not document when the most recent seizure occurred. Resident #55 was on two anti-seizure medications and an anti-anxiety medication for seizure control. Review of the resident ' s falls revealed he had fallen on 2/25/16, 3/3/16, 3/17/16 and 3/22/16. All of the falls were unwitnessed, three were during self-transfers and one occurred when he moved a tray table. No injuries occurred. Resident #55 was observed in his bed with the resident ' s right side rail up on 3/28/16 at 3:10 PM. Observations on 3/29/16 at 9:10 AM revealed the right side rail was in the up position, and a gap that measured six inches between the mattress and the side rail. Resident # 55 was not in the bed at this time. Observations with the administrator and Director of Nursing on 3/31/16 at 2:17 PM revealed Resident had used this same bed since admission. When the bed was checked by the administrator, the mattress was repositioned on the bed frame. The left side rail was not used for the resident. The mattress was not the same size as the bed frame width and would slide. When the mattress was moved, a gap of four inches remained between the side rail and mattress. Interview with Resident #55 on 3/30/16 at 11:23 AM revealed he usually slept in his recliner, but occasionally used his bed. On 3/31/16 at 10:22 AM interview was conducted with the maintenance director. Interview revealed he was not aware of the gap between the side rail and the mattress on the resident's bed. He explained the size of the mattress makes a difference. The mattress that was on his bed was a slim mattress. It was not a regular size which would fit the frame. Housekeeping would put the mattresses on the beds. He did monthly checks for safety on beds. The safety checks included the brakes, side rails, and functioning. He had not had any requests to check the bed's side rails from staff. The bed he had was an old hill rom bed. The bed was changed out on 3/31/16 per resident request due to the height of the bed. The new bed had side rails without a space between the side rail and mattress. 3. A continuous observation on 3/30/16 from 8:00am to 8:30am of facility handrails revealed one handrail on the 200 hall was missing a cover for the end of the handrail. Due to the missing cover, one nail was exposed with the sharp end visible. Review of the facilities maintenance requisitions from 2/1/16 through 3/30/16 revealed no requests in regards to an exposed nail due a missing end cover. Interview with the Maintenance Director on 3/30/16 at 3:09 pm revealed he was notified of maintenance requests by staff, residents and family. When staff observed a maintenance need they were to fill out a maintenance requisition. The Maintenance Director stated he checked the handrails through daily rounds. The Maintenance Director indicated he was aware that there was a missing cover to handrail on the 200 hall. He could not identify how long the rail had been missing the cover. He indicated he was unaware that a screw was exposed due to the missing handrail cover.

Based on record review, observation and staff and resident interview, the facility failed to honor resident's choice for not having the indwelling catheter for 1 of 1 sampled resident with an indwelling catheter.(Resident # 24) Findings included: Resident #24 was admitted to the facility on [DATE] and was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #24 had severe cognitive impairment, had a stage IV pressure ulcer (not present on admission) and had an indwelling catheter. The assessment indicated that Resident #24 had no behavioral symptoms. The care plan dated 12/11/13 was reviewed. One of the care plan problems was " at risk for loss of skin integrity and UTI related to impaired mobility and incontinence of bowel and bladder. Has stage III area to sacrum and using Foley to aid in healing. " On 1/14/14, a statement was added at the bottom of the care plan problem which read " noted to be pulling at Foley related to anxiety. " The nurse's notes were reviewed. The notes indicated that Resident #24 had multiple episodes of pulling out the indwelling catheter. She had pulled her catheter out 16 times in the last 2 months. The nurse's notes revealed that Resident #24 had pulled the indwelling catheter out on 1/3/14, 1/9/14, 1/12/14 (2 times), 1/14/14, 1/19/14, 1/20/14, 1/24/14, 2/16/14, 2/19/14, 2/22/14 (2 times), 2/23/14 ( 2 times) and 2/24/14 (2 times). On 1/12/14 at 4:30 PM, the notes indicated that Resident #24 had pulled her catheter out. When the nurse asked her why she kept pulling out her catheter, she replied in tearful tones (name of doctor) discontinued this cause I told him I hated it. " The notes further indicated that the catheter was replaced and education was given to the resident about the importance of leaving the catheter in place. The resident voiced understanding but remains tearful. On 1/12/14 at 9:46 PM, the notes indicated that the nurse was alerted that Resident #24 had pulled out her catheter for the second time in the shift. The nurse asked her why she pulled it out and she replied " cause it hurts and I don't want it in (G -D). " Resident #24 also told the nurse " if you put that thing back in me I will never talk to you again (D). " The notes revealed that the physician was informed of the resident's increased agitation with an order to give [MEDICATION NAME] (antianxiety) 0.5 milligram (mgs) times 1 dose. [MEDICATION NAME] was administered by mouth with little effect. The catheter was replaced and the resident had yelled obscenities at the nurse throughout the insertion. On 2/19/14 at 9:22 PM, the notes indicated that it was reported to the nurse that the catheter of Resident #24 was lying inside her brief. Resident #24 stated " I pulled it out on purpose cause I don't want it. " On 2/22/14 at 6:36 AM, the notes indicated that the nurse was informed that the catheter of Resident #24 was not in place. The nurse asked her what happened and she stated " it was hurting so I pulled it out. " On 2/22/14 at 9:37 PM, the notes revealed that the nurse was informed that the catheter of Resident #24 was lying inside the brief. The resident stated to the nurse " it hurts so I pulled it out. " The resident was crying while she was speaking to the nurse. Resident #24 was educated on the importance of leaving the catheter in place. The resident refused to voice understanding. The catheter was replaced and the resident was with severe anxiety/tearfulness. [MEDICATION NAME] was administered as ordered. On 2/23/14 at 12:44 PM, the notes indicated that that the catheter of Resident #24 was lying in bed with the bulb inflated. The resident stated " it hurts so I got it out. " On 2/23/14 at 10:00 PM, the notes indicated that the catheter of Resident #24 was found lying in her brief with bulb inflated. The resident was crying and not speaking. The nurse attempted to calm the resident without success. The catheter was replaced and the resident was yelling " I'm sore. " This nurse explained to resident that soreness could be the result of pulling out of the catheter multiple times. Resident refused to acknowledge the nurse. On 2/24/14 at 6:31 AM, the notes indicated that it was reported to the nurse that the catheter of Resident #24 was hanging out. The catheter was found inside the brief with the balloon inflated. Resident stated " I took it out. " When questioned why she pulled it out, the resident stated " because it was hurting. " On 2/26/14 at 3:54 PM, Resident #24 was observed in bed with the indwelling catheter in place. When asked why she was pulling her catheter out, she replied " because I don't like it. " The doctor's progress notes were reviewed. The notes dated 1/14/14 indicated that Resident #24 had the indwelling catheter to help sacral wound dry but she (resident) has been pulling the catheter and taking it out. She had pulled it out six times over the weekend and again today. The notes further indicated that the resident stated that she does not like the catheter. On 2/26/14 at 9:45 AM, administrative staff #2 was interviewed. She stated that the pulling out of the catheter by Resident #24 was a behavioral issue. On 2/26/14 at 1:41 PM, Nurse #5 was interviewed. She stated that Resident #24 had pulled her catheter out several times with the bulb inflated. She added that the physician was aware of her behavior of pulling out her catheter and he ordered to reinsert the catheter. She also stated that Resident #24 had an order for [REDACTED]. On 2/27/14 at 8:23 AM, administrative staff #5 was interviewed. She stated that she was aware that Resident #24 had been pulling her catheter out because she did not like it. She indicated that she had informed the physician about it but he preferred to leave the catheter in to help the sacral wound to heal. On 2/27/14 at 8:45 AM, administrative staff #2 was interviewed. She stated that the physician was informed of resident's pulling the catheter out and he ordered to start [MEDICATION NAME] to minimize her behavior and anxiety. She added that the physician was also informed that the resident preferred not to have the catheter but he said to leave the catheter in because of the pressure ulcer. On 2/27/14 at 8:45 AM, the physician was interviewed. The physician stated that he was aware that Resident #24 had been pulling her catheter out for the past 2 months now. He stated that it was attention seeking behavior and he discussed it with the resident and the resident stated that she did not like the catheter. He further stated that he added a scheduled [MEDICATION NAME] to calm her down and to reduce her anxiety.