Every finding on record at Chadwick Community Care Center

Based on record review, facility policy review and interviews, the facility failed to consult with the primary care provider regarding the psychosocial status of the resident which resulted in missed dialysis treatments for one (1) of three (3) residents dependent on dialysis treatments. Resident #1. Findings Included:Record review of the facility policy, Change in a Resident's Condition or Status revised February 2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times) . On [DATE] at 1:32 PM during a telephone interview, the Resident Representative (RR) for Resident #1 revealed that she was concerned related to Resident #1 missing medical and dialysis appointments. She confirmed that the Assistant Director of Nurses (ADON), had reported that the resident was verbally combative toward staff and resistant to care with Licensed Practical Nurse (LPN) #1 on [DATE] and the Medical Records Nurse on [DATE]. The ADON had reported to her that Resident #1 had missed his dialysis treatments and she said that he was not able to make up the treatment on [DATE] due to their son's funeral. She was not aware of any grief counseling offered to the resident following the death of their son.On [DATE] at 3:30 PM interview with LPN #1 revealed he notified the dialysis center and the RR that the resident missed his dialysis treatment on [DATE]. On [DATE] at 9:49 AM, during an interview with the Nurse Practitioner (NP) #1, corroborating NP for Medical Doctor (MD) #1, revealed that she was on vacation the week of [DATE] and that NP #2 had visited the resident on [DATE]. She stated, following her review of her records, that she was not notified that Resident #1 had missed dialysis treatments on [DATE] or [DATE] and that there was no documentation that NP #2 was notified. She stated that she was able to refer residents to the contract, in-facility psychiatric services and that she would have had she been notified that his behaviors were interfering with his dialysis treatments or that his son had died in [DATE].On [DATE] at 2:00 PM, during an interview with Minimum Data Set (MDS) Nurse revealed that if a behavior was displayed or documented by a resident within seven (7) days of the Quarterly MDS assessment, it should be documented in Section E of the MDS by the Social Services Director (SSD), who was responsible for Behavior Assessment. She stated that if there had been a change in the behavior of the resident that affected resident care, the resident's RR and primary healthcare provider should be notified. She confirmed that the facility had contract, in-facility psychiatric care and that residents with behaviors that had the potential to affect their health or care could be referred to the service. On [DATE] at 2:20 PM, during an interview the SSD confirmed she completed cognition, mood and behavior sections of the Quarterly MDS. She confirmed that she was aware that Resident #1 had verbal outburst, cursed and used derogatory language toward staff. She said she did not know if any other staff had reported the behaviors to the resident's primary healthcare provider, but she had not. She confirmed that she was also able, along with other staff, to refer any resident to contract, in-facility psychiatric services and that Resident #1 had not been referred.On [DATE] at 2:52 PM, during an interview the Director of Nurses (DON) confirmed that dialysis treatments were necessary for Resident #1 and that any behavior that interfered with his receiving necessary care should be identified and addressed with his primary healthcare provider. She stated that the reason Resident #1 missed dialysis treatment on [DATE] was his behavior and make up day was scheduled for [DATE]. He missed the dialysis treatment on [DATE] because of the resident's behavior. She confirmed that the dialysis center wanted him to come on [DATE] for dialysis, in addition to the [DATE] visit that he attended, but he was unable to go on [DATE] because that was the day of his son's funeral. She said that the resident showed change of behavior during his stay and, Sometimes he is nice. She stated that she was not sure what the trigger was, but staff received the brunt of his behavior. She confirmed that she had not made a referral to behavioral health contract services or notified the resident's doctor or nurse practitioner that his behaviors interfered with his receiving his dialysis treatments as ordered and scheduled. She confirmed that the documentation dated [DATE] of the missed dialysis treatment did not include notification of the resident's primary health care provider.On [DATE] at 3:25 PM, during an interview the Administrator, confirmed that communication was important, and she expected staff to make all appropriate notifications to primary healthcare providers that may negatively affect resident health. She confirmed that the facility contracted in-facility psychiatric services which were available to all residents and required referral. She stated that she was not aware that Resident #1 had not been referred for grief counseling or for psychiatric services and that both would be appropriate for Resident #1. Record review of the admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses that included end stage renal disease (present on admission), and complete traumatic amputation of two or more right lesser toes with onset date [DATE].Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section E indicated Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Record review of the Order Review History Report for Resident #1 revealed an active order with start date [DATE] for hemodialysis every Mon(day), Wed(nesday), Fri(day) @0620 (6:20) AM, (Proper name of transport company) to transport.for end stage renal disease.

Based on record review, facility policy review, and interview the facility failed to develop a person-centered comprehensive care plan to meet and address the resident's psychosocial needs for one (1) of four (4) sampled residents. Resident #1.Findings Included:Record review of the facility policy, Interdisciplinary Comprehensive Care Planning with effective date 6/02/16 revealed, The comprehensive care plan is an interdisciplinary communication tool It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The interdisciplinary team in conjunction with the resident and his/her family and/or responsible party as appropriate will develop, evaluate and amend as needed.Record review of the care plans for Resident #1 revealed there was not a care plan in place that addressed resident behaviors or psychosocial needs.On 6/30/26 at 12:50 PM, during an interview with Resident #1, he revealed that he required assistance and confirmed that he had a habit of cursing staff.On 7/02/26 at 8:44 AM, during a telephone interview the Medical Record Nurse stated that he was not aware of a care plan that addressed the behaviors that negativity affected Resident #1's health or his care. He confirmed that missing dialysis treatments had the potential to negatively affect the resident's health. On 7/02/25 at 10:24 AM, interview with Licensed Practical Nurses (LPN) #2 revealed she had witnessed Resident #1 being verbally abusive, using vulgar language toward staff, refusing care and medications and this was reported to the Director of Nursing (DON) who went into his room and received the same treatment. She stated that the resident's behavior was so egregiously abusive that there were times when direct care staff, following multiple attempts, would refuse to go back into his room to provide care. She said she was not aware of any care plan that addressed the resident's behaviors. On 7/02/26 at 11:00 AM, during a record review and interview with Certified Nursing Assistant (CNA) #2 confirmed that he was assigned to the care of Resident #1 on 7/02/26. CNA #2 reported that Resident #1 displayed verbally aggressive behavior that erupted with no warning and resulted in the resident demanding him to get out of his room. He stated that he was not aware of any specific interventions developed to address the behavior of Resident #1. The record review revealed CNA #2 accessed care instructions for Resident #1 on the resident care software with no interventions for behaviors listed. On 7/02/26 at 12:22 PM, during an interview with the Assistant Director of Nurses (ADON) revealed no one notified her that Resident #1 missed dialysis treatments on 6/10/26 and 6/11/26. She stated that she was not aware of any care plan or person-centered interventions that addressed Resident #1's behaviors.On 7/02/26 at 2:20 PM, during an interview the Social Services Director (SSD) revealed Resident #1 had no care plan developed that addressed his behavior. She confirmed that she was aware that Resident #1 had verbal outburst, cursed and used derogatory language toward staff. On 7/02/26 at 2:52 PM, the DON said she was not aware that a care plan was not in place to address Resident #1's behaviors that affected the resident's care or psychosocial needs or a care plan related to the death of his son. She confirmed that dialysis was necessary care for Resident #1 and that any behavior that interfered with his receiving needed or necessary care should be identified and addressed. On 7/02/26 at 3:25 PM, during an interview the Administrator said she expected individualized care plans to be developed and implemented for each resident. She stated that the purpose of the care plan was to provide staff with interventions for the care of each resident. She confirmed that the care plan also provided measurable goals which enabled nursing staff to assess the effectiveness of approaches. Record review of the admission Record revealed the facility admitted Resident #1 on 11/12/24 with diagnoses that included of end stage renal disease (present on admission), and complete traumatic amputation of two or more right lesser toes with onset date 6/18/25.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section E indicated Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others).

Based on facility policy review, record review and interviews, the facility failed to provide the appropriate treatment and services to address known psychosocial concerns in order to attain the highest practicable mental and psychosocial well-being for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility policy, Behavioral Health Services with Revised Date February 2019 revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.During a telephone interview, on [DATE] at 1:32 PM, the Resident Representative (RR) for Resident #1 revealed that she was concerned related to the resident missing medical and dialysis appointments. She confirmed that the Assistant Director of Nurses (ADON), had reported that the resident was verbally combative toward staff and resistant to care. She said that Licensed Practical Nurse (LPN) #1 on [DATE] and the Medical Records Nurse on [DATE] had reported to her that Resident #1 had missed his dialysis treatments. Resident #1 stated that he could not make up the treatment on [DATE] due to their son's funeral. She was not aware of any grief counseling offered to the resident following the death of their son.During an interview on [DATE] at 9:49 AM, Nurse Practitioner (NP) #1, corroborating NP for MD #1, revealed that she was on vacation the week of [DATE] and that NP #2 had visited the resident on [DATE]. She stated, following her review of her records, that she was not notified that Resident #1 had missed dialysis treatments on [DATE] or [DATE] and that there was no documentation that NP #2 was notified. She stated that she was able to refer residents to the contract, in-facility psychiatric services and that she would have made the referral, had she been notified that his behaviors were interfering with his dialysis treatments or that his son had died in [DATE].During an interview on [DATE] at 2:00 PM, the Minimum Data Set (MDS) Nurse revealed that if a behavior was displayed or documented by a resident within seven (7) days of the Quarterly MDS assessment, it should be documented in Section E of the MDS by the Social Services Director (SSD), who was responsible for Behavior Assessment. She stated that if there had been a change in the behavior of the resident that affected resident care, the resident's RR and primary healthcare provider should be notified. She confirmed that the facility had contract, in-facility psychiatric care and that residents with behaviors that had the potential to affect their health or care could be referred to the service.During an interview on [DATE] at 2:20 PM, the Social Services Director (SSD) confirmed she completed cognition, mood and behavior sections of the Quarterly MDS. She confirmed that she was aware that Resident #1 had verbal outburst, cursed and used derogatory language toward staff. She said she did not know if any other staff had reported the behaviors to the resident's primary healthcare provider, but she had not. She confirmed that she was also able, along with other staff, to refer any resident to contract, in-facility psychiatric services and that Resident #1 had not been referred.During an interview on [DATE] at 2:52 PM, the Director of Nurses (DON) confirmed that dialysis treatments were necessary for Resident #1 and that any behavior that interfered with his receiving necessary care should be identified and addressed with his primary healthcare provider. She stated that the reason Resident #1 missed dialysis treatment on [DATE] was his behavior and make up day was scheduled for [DATE] and he missed dialysis treatment on [DATE] because of the resident's behavior. She confirmed that the dialysis center wanted him to come on [DATE] for dialysis, in addition to the [DATE] visit, but he was unable to go on [DATE] because that was the day of his son's funeral. She said that the resident had shown a change in behavior during his stay. The DON stated that, Sometimes he is nice. She stated that she was not sure what the trigger was, but staff received the brunt of his behavior. She confirmed that she had not made a referral to behavioral health contract services or notified the resident's doctor or NP that his behavior interfered with his receiving his dialysis treatments as ordered and scheduled. She confirmed that the documentation dated [DATE] of the missed dialysis treatment did not include notification of the resident's primary health care provider.During an interview on [DATE] at 3:25 PM, the Administrator confirmed that communication was important, and she expected staff to make all appropriate notifications to primary healthcare providers that may negatively affect resident health. She confirmed that the facility contracted in-facility psychiatric services were available to all residents and required a referral. She stated that she was not aware that Resident #1 had not been referred for grief counseling or for psychiatric services and that both would be appropriate for Resident #1. Record review of the admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses that included of end stage renal disease (present on admission), and complete traumatic amputation of two or more right lesser toes with onset date [DATE].Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section E indicated Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Record review of the Order Review History Report revealed an active order with start date [DATE] for Hemodialysis every Mon(day), Wed(nesday), Fri(day) @0620 (6:20) AM.(Proper name of transport company) Transportation to transport.for end stage renal disease. He did not have any physician's orders for any psychoactive medications.

Based on observations, interviews, record review and facility policy review, the facility failed to consistently provide necessary activities of daily living (ADL) care, including daily oral hygiene, routine nail care, and regular shaving of facial hair for one (1) of (19) residents reviewed. Resident #78.Findings include: Record review of the facility policy, Activities of Daily Living (ADL's) Supporting revised March 2018, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.On 1/27/26 at 11:51 AM, during an interview with Certified Nursing Assistant (CNA) #1, he stated that he had been assigned to provide ADL care to Resident #78 for the past two days. He explained that oral care and grooming, such as shaving, are routine parts of ADL care. He acknowledged that he had failed to perform this type of ADL care for Resident #78 but stated he could do it now if the State Agency (SA) would like him to.On 1/27/2026 at 11:54 AM, during an interview with Resident #78, she stated that things are going okay at the facility. She reported that she wants her teeth brushed daily but cannot remember the last time staff brushed them because she needs their help to do so. She added that staff do not often cut her nails, and the nails on her contracted hand are long and digging into her skin and she would like them trimmed. She also mentioned that she dislikes the hair under her chin and requests that the staff keep it trimmed regularly. Observation of Resident #78's nails revealed they were long and digging into the skin of her contracted hand, leaving a deep impression. The resident's facial chin hair was long, gray, and curled to the point of resembling a beard. There was an extremely large amount of plaque buildup on her teeth, indicating they had not been brushed in quite some time.On 1/27/26 at 12:04 PM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the hair under Resident #78's chin had not been shaved in quite some time. She stated that the CNA's role is to ensure it is cut as needed. During the assessment of Resident #78's nails on her contracted left hand, LPN #1 confirmed to the SA that the nails were long, leaving a deep indentation in her skin, and could cause further injury if not cut. She also acknowledged that Resident #78's teeth had extensive plaque buildup and needed to be brushed.On 1/28/26 at 11:45 AM, during an interview with the Director of Nursing (DON), she stated that CNAs are required to perform oral care and facial grooming, such as removing facial hair, but that nurses are responsible for cutting residents' nails. In an interview with CNA #2 on 1/28/26 at 2:36 PM, she stated that removing facial hair and providing oral care are routine parts of ADL care. She explained that she removes facial hair to help residents feel more confident, and that oral care is important to prevent cavities and bad breath.Record review of the admission record revealed the facility admitted the resident on 1/15/21 with diagnoses including unspecified osteoarthritis, unspecified site. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/25 revealed a Brief Interview Mental Score (BIMS) of (15) indicating the resident is cognitively intact.

Based on observation, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan related to Activities of Daily Living (ADL) and wound care for two (2) of six (6) care observations. Resident #60 and Resident #78. Findings Include: Record review of the facility policy Comprehensive Person Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Resident #60 Record review of Resident #60's Care Plan Report with a date initiated of 12/29/2025 revealed .Approaches/Tasks: Cleanse site with wound cleanser, pat dry, apply skin preparation and barrier cream, and cover with a dry dressing daily and as needed . On 01/28/2026 at 1:39 PM, an observation of wound care was conducted by Licensed Practical Nurse (LPN) #4. LPN#4 cleansed the wound with wound cleanser but did not pat dry prior to betadine application as ordered by the physician orders and the comprehensive care plan. On 01/28/2026 at 3:05 PM, during an interview, LPN #4 stated he was not aware he failed to pat the wound dry. He stated patting the wound dry creates a dry barrier that supports wound healing. He stated he did not follow the care plan. On 01/29/2026 at 3:10 PM, during an interview, the Director of Nursing (DON) stated staff are expected to follow the comprehensive care plan because it informs staff of the care required. She stated she expects staff to follow the care plan. Record review of Resident #60's admission Record revealed an admission date of 09/29/2025 with diagnoses that included Type 2 Diabetes Mellitus without complications and Hypertensive Heart Disease without Heart Failure. Record review of Resident #60's Order Summary Report with active orders as of 1/29/26 revealed a physician order dated 1/9/26 for intact blister to the left heel to be cleansed with wound cleanser, patted dry, betadine applied daily, and covered with a dry dressing as needed. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. Resident #78 Record review of the Care Plan Report with a revision date of 6/18/25 revealed Problem.has potential for ADL self-care deficit related to she requires staff for assistance.Approaches. Dressing, grooming, personal hygiene x 1 person assistance.Oral hygiene-substantial to maximal assistance x 1. On 01/27/2026 at 11:54 AM, during an interview, Resident #78 stated things were going okay at the facility. She stated she wants her teeth brushed daily but cannot remember the last time staff brushed them because she requires staff assistance. She stated staff do not often cut her nails and the nails on her contracted hand are long and digging into her skin. She stated she would like them trimmed. She also stated she dislikes the hair under her chin and requests staff keep it trimmed regularly. On 01/28/2026 at 5:36 PM, during an interview, the Registered Nurse (RN) and MDS nurse stated the purpose of the care plan is to provide a plan of care for staff to follow and for families to understand the care being provided. She stated nurses and Certified Nursing Assistants (CNAs) are expected to follow the care plan and if they do not, they are not following the established plan of care. She stated all staff should be following it. Record review of Resident #78's admission Record revealed an admission date of 01/15/2021 with diagnoses including unspecified osteoarthritis, unspecified site. Record review of the MDS with an ARD of 11/25/2025 revealed a BIMS score of 15, indicating the resident is cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to follow standards of practice during medication administration and wound care for two (2) of five (5) residents observed for medication administration and wound care. Residents #8 and #60.Findings Include: Record review of the facility policy Wound Care, revised 1/9/22, revealed The purpose of the procedure is to provide guidelines for the care of wounds to promote healing . Record review of the facility policy Administering Medications through an Enteral Tube, undated, revealed, General Guidelines. Administer each medication separately and flush between medications . Resident #8 On 01/28/2026 at 8:30 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications to Resident #8 via percutaneous endoscopic gastrostomy tube. During medication administration, the nurse administered multiple medications through the tube without flushing with water between each medication. The tube became clogged, requiring the nurse to use a syringe plunger to push the medications after gravity flow stopped. On 01/28/2026 at 9:51 AM, during an interview, LPN #1 confirmed she did not flush the feeding tube with water between each medication. She confirmed the physician order required a 15-milliliter (ml) flush between each medication. She stated complications of not following the order could include tube clogging, difficulty with medication administration, and possible need for emergency room transfer to clear or replace the tube. On 01/28/2026 at 11:49 AM, during an interview, the Director of Nursing (DON) stated the feeding tube should have been flushed with 15 ml of water between each medication to prevent clogging. She stated nurses are expected to follow physician orders. Record review of Resident #8's admission Record revealed an admission date of 08/15/2023 with a diagnoses that included peritoneal abscess. Record review of Resident #8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Record review of Resident #8's Order Summary Report with active orders as of 1/28/26 revealed a physician order to flush the feeding tube with 60 cubic centimeters (cc's) of water before and after medication administration, flush with 15 cc's between medications, and dilute medications with 5 cc's of free water. Resident #60 On 01/28/2026 at 1:39 PM, an observation of wound care was conducted by LPN #4. LPN#4 cleansed the wound with wound cleanser but did not pat dry prior to betadine application as ordered by the physician orders. On 01/28/2026 at 3:05 PM, during an interview, LPN #4 stated he was not aware he failed to pat the wound dry. He stated patting the wound dry creates a dry barrier that supports wound healing. On 01/29/2026 at 3:10 PM, during an interview, the DON stated LPN #4 should follow physician orders when performing wound care. She stated the wound should have been patted dry prior to betadine application. She stated the purpose of patting the wound dry is to remove excessive moisture. She stated excessive moisture can delay healing and cause maceration. Record review of Resident #60's admission Record revealed an admission date of 09/29/2025 with diagnoses that included Type 2 Diabetes Mellitus without complications and Hypertensive Heart Disease without Heart Failure. Record review of Resident #60's Order Summary Report with active orders as of 1/29/26 revealed a physician order dated 1/9/26 for intact blister to the left heel to be cleansed with wound cleanser, patted dry, betadine applied daily, and covered with a dry dressing as needed. Record review of the MDS with an ARD of 12/29/2025 revealed a BIMS score of 13 indicating the resident is cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured with a leg strap for one (1) of four (4) residents reviewed with urinary catheters. Resident #2.Findings Include:Record review of the facility policy Catheter Care, Urinary, undated, revealed .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site .On 01/29/2026 at 10:53 AM, during an observation and interview of foley catheter care conducted by Certified Nursing Assistant (CNA) #3, assisted by CNA #4 revealed upon removal of Resident #2's pajamas a leg strap to secure the catheter was not in place. CNA #3 and CNA #4 confirmed there was not a leg strap in place to secure the catheter. CNA #4 stated Resident #2 should have a leg strap. She stated the purpose is to prevent the catheter from pulling out. She stated she notifies the nurse when one is not present.On 01/29/2026 at 2:56 PM, during an interview, the Director of Nursing (DON) stated CNAs should apply a leg strap during care and do not need to notify a nurse to do so. She stated the purpose of the leg strap is to keep the catheter in a stationary position to prevent dislodgement or injury. She stated staff are expected to follow the plan of care and apply the leg strap.Record review of Resident #2's admission Record revealed an admission date of 02/05/2025 with diagnoses that included Neuromuscular Dysfunction of the Bladder.Record review of the Order Summary Report with active orders as of 1/29/26 revealed physician orders dated 11/17/25 for catheter care with soap and water each shift and as needed, and to observe for placement of a catheter leg strap with tubing secured each shift.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2026 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were clinically indicated and free from unnecessary use for one (1) of seven (7) sampled residents reviewed for unnecessary medications. Resident #5.Findings Include:Record review of Resident #5's medication orders revealed an active order for Narcan Nasal Liquid 4 milligrams per 0.1 milliliters, spray alternating nostrils every two minutes as needed for signs and symptoms of overdose including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the Medical Doctor and Emergency Medical Services immediately. (Narcan is indicated to reverse the effects of opioid overdose.) Record review of Resident #5's medication orders revealed an active order for Narcan Nasal Liquid 4 milligrams per 0.1 milliliters, spray alternating nostrils every two minutes as needed for signs and symptoms of overdose including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the Medical Doctor and Emergency Medical Services immediately.Record review of the Order Summary Report revealed Resident #5 did not have any opioids ordered. The only sedative medication ordered was Clonazepam 0.5 milligrams, give 0.25 milligrams by mouth every 12 hours related to anxiety disorder. While Clonazepam may cause sedation, unresponsiveness, or respiratory depression, these effects are not reversed by Narcan, rendering the order clinically unnecessary and non-beneficial to the resident.On 01/29/2026 at 12:15 PM, during an interview, the Director of Nursing confirmed Resident #5 did not have any opioids ordered. She stated she needed to review the pharmacologic action of Narcan to determine if it would reverse the effects of Clonazepam. After reviewing the medication orders and drug action, she confirmed Narcan would not benefit the resident if unresponsiveness occurred from Clonazepam use. She stated the order was likely selected in error when a nurse submitted a batch of orders to the provider for signature. She stated the order did not apply to the resident and was selected by mistake. She further acknowledged that if she had to research the drug action, it would be difficult to expect nursing staff to appropriately select medications without error.Record review of Resident #5's admission Record revealed an admission date of 11/09/2015 with a diagnoses that included paroxysmal atrial fibrillation.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2026 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment.

Based on observation, interview and record review the facility failed to provide alternative menu choices and ensure meal preference options were communicated for one (1) of (19) sampled residents reviewed for food service choices. Resident #70.Findings Include:On 01/27/2026 at 12:32 PM, during an interview, Resident #70 stated he sometimes does not like the food he is served. He stated he did not know alternate meals were available. He stated when he tells the Certified Nursing Assistants (CNAs) he does not like the meal served, sometimes they bring something else and other times they do not. He stated he is not aware of what foods are being served daily and would like to know what is being served.On 01/28/2026 at 11:06 AM, during an interview, Resident #70 stated he still did not know what foods would be served that day. Observation of the resident's room revealed there was not a menu posted in the room.On 01/28/2026 at 11:23 AM, during an interview, the Dietary Manager stated menus are posted on each hall. She stated CNAs ask residents at lunch and notify kitchen staff of resident choices. She stated culinary meetings are held on Fridays with approximately 35 residents attending. She stated the weekly menu is reviewed at that time and residents may voice concerns. She confirmed that all residents do not attend the meetings.On 01/28/2026 at 3:00 PM, during an interview, CNA #3 stated she was assigned to Resident #70. She stated she passes breakfast and lunch trays. She stated if residents do not want the meal served, she goes to the kitchen to ask about alternatives. She stated she does not know alternate meals until residents refuse the tray. She stated she does not inform residents of alternative lunch or dinner options in advance because she does not know them until she asks dietary staff. She stated residents are not told of the alternatives unless they refuse the meal after trays are served.On 01/29/2026 at 3:16 PM, during an interview, the Director of Nursing stated menus are posted near the dining room and on meal carts so staff can inform residents of alternative meals. She stated it is important that residents are given choices and informed prior to mealtimes so they can participate in care decisions. She stated her expectation is for CNAs to inform residents of meal options before trays are served.Record review of Resident #70's admission Record revealed an admission date of 07/18/2022 with diagnoses that included of Hypertensive Heart Disease without Heart Failure and Hyperlipidemia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control guidelines during medication administration for one (1) of four (4) residents reviewed for medication administration. Resident #8. Findings Include:Record review of the facility policy, revised October 2018, revealed This facility's infection control policies and practices are intended to. help prevent and manage transmission of disease and infection.On 01/28/2026 at 8:30 AM, medication administration was observed for Resident #8 via percutaneous endoscopic gastrostomy tube. Prior to administration, Licensed Practical Nurse (LPN) #1 removed the stopcock plunger from the feeding tube syringe and placed it on top of the plastic container it came in. During medication administration, the stopcock plunger slid off the plastic container onto the bare bedside table, which had not been disinfected prior to medication preparation. During the medication administration process, the resident's feeding tube became clogged, requiring LPN#1 to use the stopcock plunger to push the medication through the tube. LPN#1 did not disinfect the stopcock plunger after it contacted the bedside table. The plunger was placed directly back into the syringe and used to administer medication into the resident's feeding tube.On 01/28/2026 at 9:51 AM, during an interview, LPN#1 confirmed the stopcock plunger had been resting on the bedside table prior to use. She stated proper infection prevention practice would have required disinfecting the bedside table prior to medication administration or discarding the contaminated syringe and stopcock and obtaining a new one. She stated failure to follow infection prevention guidelines could result in transmission of infection to the resident.On 01/28/2026 at 11:49 AM, during an interview, the Director of Nursing (DON) stated LPN#1 should have disinfected the bedside table prior to medication administration and used a clean barrier before placing equipment on the surface. She stated once the syringe plunger contacted the table, the nurse should have obtained a new syringe or disinfected the equipment prior to use. She stated potential complications of this practice include transmission of infection to the resident. She stated it is her expectation that nurses follow infection prevention guidelines during medication administration.Record review of Resident #8's admission Record revealed an admission date of 08/15/2023 with a diagnoses that included peritoneal abscess.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.

Based on interviews, record review, and facility statement review the facility failed to issue a bed-hold notice when a resident went out on therapeutic leave for one (1) of two (2) residents reviewed for discharge. (Resident #1).Findings Include:Record review of a typed statement on facility letterhead and signed by the Executive Director (ED) revealed, The facility does not have a policy for Bed Hold. On 09/15/25 at 4:42 PM, in an interview the ED stated Resident #1 was discharged due to escalating behavior. She would pull her dress while walking down the hall and go into male residents' rooms. She stated Resident #1 was discharged for her safety and welfare. She stated the facility could not meet her needs. She stated Resident #1's family declined the 30-day notice. Resident#1 left on 5/30/25 and family decided to take resident home. Resident was discharged on 5/30/25 due to the family decision.On 09/16/25 at 10:58 AM, a phone interview with Resident #1's Resident Representative (RR) stated that Resident #1 is with her sister at this time. The RR stated he received only one letter from the facility, and it was certified. He stated it took him a while to get the letter because he works nights and by the time he woke up post office was closed. He stated he was given a second discharge letter when he came to pick up personal belongings and medication on 6/2/25. He stated he was not aware and did not understand the appeal process. He stated he contacted the Ombudsman and was told there was nothing he could do about it. The RR stated when her sister picked up Resident #1 on 5/30/25 they did not inform her that Resident #1 was being discharged . The RR stated her sister tried to bring her back Sunday and was told resident was discharged on Friday. He stated Resident #1 did not have enough medications for all those days. He stated when Resident #1 left Friday they did not remove the wander guard, and it is still attached to her leg now. He stated if she was discharged on 5/30/25 they should have removed the wander guard at that time. He stated they only gave her enough medicine for the three (3) days she was on leave with her sister. He stated when her sister tried to return her Sunday, they met them at the door and told them she couldn't bring her back. He stated she requires help with activity of daily living (ADL) care, and they did not provide home health. The RR stated the facility contacted him to come get her personal belongings and medication.On 09/16/25 at 12:09 PM, in an interview the Social Worker (SW) stated that Resident #1 was not eligible for home health, and she has Medicaid. She stated home health requires Medicare. She stated she could not set it up because the resident did not have a payor source. She stated Resident#1 went on an outing on 5/30/25 with family and did not return and she was discharged when she did not return to the facility.On 09/16/25 at 1:07 PM, during an interview, the Director of Nursing (DON) started Resident #1 left on 5/30/25 and the facility knew she was not coming back. She stated the resident was discharged on 5/30/25 and family was aware. She stated a nurse phoned her and told her resident was leaving and she informed nurse to give the resident her medication. She stated she told nurse that she would contact the RR about picking up personal belongings and medication. She stated the RR came back Monday to pick up medications and instructions on how to give medication. She stated the residents have supportive families and would go on leave often with family. The DON stated the RR would have to come back Monday to get all medications and personal items. They only give personal items to the RR.On 09/16/25 at 1:45 PM, an interview with Business Office Manager (BOM) stated there are two types of bed hold. There is a 15-day bed hold when a resident goes out on therapeutic leave. She stated when a resident goes on therapeutic leave, they do not notify the family about bed hold. On 09/16/25 at 3:18 PM, in an interview with the ED, she stated therapeutic leave is when a resident leaves the facility with family. The family lets the facility know and the nurse documents in the chart, give medication to the family for the days out. She stated she calls therapeutic leave out on pass. She stated Resident #1 was out on a pass on 5/30/25 with family. She stated she found out Monday that Resident #1 did not return. She stated the resident returns on Sunday or Monday. She stated she was informed on Monday that the RR came to pick up personal items and all medications. She stated they do not give bed hold letters to family or residents when they go on therapeutic leave. She stated they only give them when resident goes to hospital and is admitted for 24 hours or more. She stated the facility has never given out bed hold letters for therapeutic leave. She stated she has been the ED at the facility for one year and 7 months.On 09/16/25 at 8:31 PM, in a phone interview with Resident #1's sister she stated she picked up Resident #1 on 5/30/25. She stated that her and the other sister take turns picking her up on the weekends. They each do two weeks out of the month. She stated when she picked up the resident nobody informed her of a discharge. She stated a nurse asked when the resident was coming back and she told them Sunday at 2:00 PM. She started to return around 2:00 PM and rang the doorbell, it took them a while before someone finally came to the door. She stated there were other people waiting to get into the facility. She stated a nurse came to the door and let the other people in the building and told her to stay right there. She stated finally a nurse came to the door and told her when you picked up Resident #1 on 5/30/25 she was discharged . They told her the RR was sent a letter. They would not let her in the building. She stated when she picked up Resident #1 she was never told about bed hold. On 09/17/25 at 10:00 AM, in an interview with the ED she stated she had done her homework on therapeutic leave and now realized they should have done bed hold on therapeutic leave.On 09/17/25 at 11:23 AM, in an interview the SW stated she was not aware that Medicaid would pay for a limited number of home health visits. She stated after Resident#1 was discharged she did not follow up with family. She stated she did not reach out to the RR. She stated she did not follow up with Resident #1 care at all.On 09/17/25 at 11:52 AM, during an interview the DON stated they remove wander guards when a resident is discharged home. She stated she was not aware that the wander guard was not removed prior to the resident being discharged on 5/30/25. She stated, The nurse should have removed it.A record review of Resident #1 Progress Notes revealed on 1/31/25, 2/7/25, -2/9/25, 2/11/25-2/13/25,2/28/25-3/2/25, 3/7/25-3/8/25, 4/4/25-4/5/25, 4/11/25-4/12/25, 4/25/25-4/26/25, 5/3/25-5/4/25, 5/23/25-5/25/25 and 5/30/25 revealed resident was out on therapeutic leave with family.A record review of Resident #1 Discharge Summary Instructions dated 6/2/25 revealed resident did not return to the facility after Therapeutic leave on 5/30/25.A record review of Resident #1 timeline provided by facility revealed that the resident was out on therapeutic leave on 1/31/25, 2/7/25 -2/9/25, 2/11/25- 2/13/25, 2/28/25-3/2/25, 3/7/25-3/9/25, 4/4/25-4/6/25, 4/11/25-4/12/25, 4/25/25-4/27/25, 5/2/25-5/4/25, 5/23/25-5/25/25 and 5/30/25 revealed resident was out on therapeutic leave with family.A record review of Resident #1 admission Record revealed an admission date of 9/22/24 with diagnoses that included Schizophrenia and Wandering in Diseases Classified elsewhere.A record review of Resident #1 Minimum Data Set (MDS) with Assessment Reference Date (ARD) 6/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicates severely cognitively impaired. Section A is coded for discharge not anticipated returning.A record review of a typed statement on facility letterhead, undated and signed by the ED revealed Facility Acquired Discharges 2025 revealed Resident #1's (proper name) was the only name listed on this form.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan while providing perineal care for one (1) of two (2) residents observed for activities of daily living (ADL) care (Resident #4).Findings Include:A record review of the facility's Comprehensive Person-Centered Care Plans dated 1/25 revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .A record review of Resident #4's Care Plan Report revealed a care plan with an initiation date of 10/2/24, Focus: (Proper name of Resident #4) is incontinent of bladder and bowel.Interventions. Incontinent checks/care every two (2) hours and as needed (PRN) x (times) 2-person assistance for total dependence . On 9/16/25 at 4:03 PM, during an observation of perineal care revealed CNA #1 provided perineal care without 2-person assistance as indicated on the care plan. On 09/16/25 at 4:16 PM, during an interview CNA #1 confirmed that he did not follow the care plan by using 2 persons for assistance with perineal care. On 09/16/25 at 5:08 PM, in an interview with Executive Director (ED) she stated, All CNAs should be able to provide care correctly.On 09/17/25 at 11:35 AM, during an interview the Director of Nursing (DON) stated CNA#1 did not follow the care plan. She stated her expectation is for CNA's is to give good quality care and follow proper procedure for giving care.On 09/17/25 at 12:55 PM, during an interview Registered Nurse (RN) #2/Minimum Data Set (MDS) nurse stated she could not comment on what CNA #1 did or did not do, she was not there when he provided the care. She stated I can only say what the care plan says. The care plan states (2) people assistance with peri care. She stated the purpose of the care plan is to inform the CNAs of the care that is to be provided. She stated the interventions indicate what the facility is doing for the residents. A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Based on observation, interviews, record reviews and facility policy review the facility failed to provide perineal (peri-care) according to acceptable standards for one (1) of two (2) observations. Resident #4.Findings Include:A record review of the facility's Incontinent Care dated 07/12 revealed .10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire perineal, wash the entire area.On 09/16/25 at 4:03 PM, in an observation, Certified Nursing Assistant #1 (CNA) provided perineal care for Resident #4. CNA #1 placed the feeding pump on hold. He used three wipes and wiped front to back in the groin area on the right side. He then folded the wipe and wiped the same area again. He retrieved three (3) more wipes and wiped the left side front to back. He picked up the remaining wipes and wiped down the center of the vagina front to back one time. He turned resident on her left side to remove soiled brief. He placed soiled brief on the bed and placed a clean brief on the resident. CNA#1 did not separate the labia and wipe down each side and the center. He did not clean the rectal area. On 9/16/25 at 4:16 PM, during an interview CNA #1 stated he had been trained to place the feeding pump on hold during care. He confirmed that he did not perform perineal care correctly. He stated he was nervous and forgot to follow proper procedure. CNA #1 acknowledged that his actions could cause Resident #4 to develop an infection.On 9/16/25 at 4:21 PM, during an interview Registered Nurse (RN) #2/ Unit Manager for the B Unit confirmed that CNA #1 did not provide care properly. She stated CNAs are not permitted to operate feeding pumps and that only nurses are authorized to do soOn 9/16/25 at 5:08 PM, during an interview the Executive Director (ED) stated that the State Agency (SA) should have picked anyone other than him to do peri care. She further stated all CNAs should be able to perform care correctly.On 9/17/25 at 11:35 AM, during an interview the Director of Nursing (DON) stated CNA #1 should have informed the nurse so she could place the feeding pump on hold, as CNAs are not permitted to operate feeding pumps. The DON stated the pump could malfunction and cause harm to the resident if not handled properly. The DON further stated CNA #1 should have performed perineal care correctly, including applying clean gloves before providing care to the buttocks and skin folds. She stated CNA #1 did not provide care correctly. The DON stated her expectation is for CNAs to provide quality care and to follow proper procedures when giving care.A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Based on observation, interview, record review, and facility policy review, the facility failed to provide perineal care in a manner that would prevent the possible spread of infection for one (1) of two (2) residents observed for perineal care. (Resident #4).Finding include:A record review of the facility's Hand Washing policy, with a history of 9/19 revealed POLICY: Staff will use proper handwashing technique to prevent the spread of infection.A record review of the facility's Enhanced Barrier Precautions (EBP) policy, with a history of 4/24 revealed . 2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident.f. Changing briefs or assisting with toileting .A record review of the Enhanced Barrier Precautions (EBP) signage revealed that everyone must clean their hands, including before entering and when leaving the room. The signage further revealed that providers and staff must wear gloves and gowns for high-contact resident care activities, including changing briefs, assisting with toileting .On 9/16/25 at 4:03 PM, observed signage on Resident #4's door that revealed that Resident #4 was on Enhanced Barrier Precautions (EBP). Personal protective equipment (PPE) was observed outside of the resident's room. CNA #1 gathered supplies consisting of a brief, perineal wipes, and gloves. He entered the room with the supplies in hand and explained the care procedure to Resident #4. CNA #1 placed the brief and wipes directly on the table without a barrier in place. He applied gloves, placed the enteral feeding pump on hold, and used the bed control to adjust the bed in preparation for care. CNA #1 removed 10 perineal wipes from the pack and placed them on top of the pack on the table. He used three wipes to clean the right groin area front to back, folded the wipe, and wiped the same area again. He retrieved three additional wipes and cleaned the left groin area front to back. He then used the remaining wipes to clean the center of the vaginal area front to back one time and placed the soiled wipes on the bed. CNA #1 turned Resident #4 onto her left side to remove the soiled brief, placed the soiled brief on the bed, and applied a clean brief. CNA #1 did not wash his hands before, during, or after providing care. He did not wear a gown or change gloves during care. CNA #1 did not separate the labia to clean each side and the center individually and did not clean the rectal area. After completing care, CNA #1 removed one glove and adjusted the bed, picked up the soiled brief and gloves, disposed of them in the garbage can, removed his final glove, and exited the room without washing or sanitizing his hands.On 9/16/25 at 4:16 PM, an interview was conducted with CNA #1. CNA #1 stated he had been trained to place the feeding pump on hold during care. He confirmed that he did not wear a gown and did not wash his hands at any point during care. He confirmed that he did not perform perineal care correctly. CNA #1 stated he was nervous and forgot to follow procedure. He stated he should have had a bag for the soiled brief and acknowledged that his actions could cause Resident #4 to develop an infection.On 9/16/25 at 4:21 PM, an interview was conducted with Registered Nurse (RN) #2, Unit Manager for the B Unit. RN #2 confirmed that CNA #1 did not provide care properly and did not wear a gown before providing care. She stated CNA #1's actions constituted cross-contamination and exposed the resident to pathogens.On 9/16/25 at 5:08 PM, during an interview, the Executive Director (ED) stated she had heard about the perineal care provided by CNA #1. She stated the State Agency (SA) should have picked anyone other than him to do care. The NHA further stated all CNAs should be able to perform care correctly.On 9/17/25 at 11:35 AM, during an interview the Director of Nursing (DON) stated CNA #1 should have followed EBP guidelines by wearing a gown. She stated CNA #1 should have used a barrier for supplies and performed hand hygiene before, during, and after care. The DON stated CNA #1 should not have touched the bed controls while wearing contaminated gloves. She further stated CNA #1 should have placed the soiled brief and wipes into a clear bag instead of on the bed, changed gloves, performed hand hygiene, and applied clean gloves before performing perineal care on the buttocks area and skin folds. The DON stated EBP is implemented to protect residents and staff from infection, and CNA #1's actions placed the resident at risk for numerous infections, including urinary tract infection. She stated her expectation is that all CNAs provide quality care and follow proper procedures when providing resident care.On 9/18/25 at 8:12 AM, during a post-survey telephone interview, Registered Nurse (RN) #3, Infection Preventionist (IP), stated CNA #1 should have washed his hands before, during, and after providing care. She stated staff are trained in EBP and should wear gowns when providing care to high-risk residents. She stated CNA #1 should have followed infection control training. RN #3 stated she has conducted several in-service trainings on infection control and EBP, and that these trainings are conducted to prevent the spread of infection and are expected to be followed.A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision of Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. On 5/09/25, at approximately 7:45 AM, Resident #1 exited the facility while unsupervised wearing a wander alarm device. The resident was out of the facility unsupervised and walked approximately one (1) mile crossing a four-lane highway for approximately two (2) hours before being located and returned to the facility. The facility's failure to provide adequate supervision for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/09/25, when Resident #1 exited the facility and existed at: 42 CRF(S): 483.25 (d)(1)(2)- Free of Accidents, Hazards/Supervision/Devises (F689). The State Agency (SA) notified the Administrator of the IJ on 5/13/25 at 3:00 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 5/9/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 5/10/25, prior to the SA's entrance on 5/13/25. Findings include: A record review of the facility's policy Missing Resident/Elopements, dated 1/15, revealed . The Unit Charge Nurse/CMT (Certified Medication Technician) is responsible for knowing the location of their residents . Procedure: . 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse/CMT as soon as possible . A record review of the facility's investigation summary, dated 5/9/25, revealed Resident #1 was last seen in the dining room at approximately 7:30 AM on 5/9/25 by a staff member. The resident was sitting at a table near the entrance to the kitchen area. At approximately 7:45 AM, a dietary staff member received a phone call from the resident's representative requesting that the staff be reminded of the resident's scheduled physician appointment. When the dietary staff looked back toward the dining room, the resident was no longer there, but his walker remained. Staff began searching the facility, and when the resident could not be located, a facility-wide elopement alert (Dr. Wander) was announced. The investigation indicated that the resident exited the facility through a kitchen door leading to a loading dock. The door was not equipped with a wander guard alert system, unlike all other facility doors. The resident had previously been identified as an elopement risk and was wearing a functioning wander guard bracelet at the time of the incident. Multiple staff members began searching the premises and the surrounding area. The resident was located at 9:20 AM by two staff members approximately one mile from the facility, walking near a busy highway. He was returned to the facility by staff at 9:32 AM and assessed by nursing and administrative personnel. The head-to-toe assessment revealed no signs of injury, distress, or trauma, and the resident was appropriately dressed and alert. According to the facility's documentation, the resident stated he was trying to go home and had exited through the kitchen door. Following the incident, the facility initiated corrective actions including environmental safety reviews, elopement drills, staff in-servicing, and the installation of additional wander guard systems. The resident's care plan was updated, and one-on-one supervision was implemented. A quality assurance meeting was held, and further audits and safety measures were initiated to prevent recurrence. A record review of the Admission Record revealed the facility admitted Resident #1 on 04/01/25 with diagnoses including Schizophrenia. A record review of the Order Summary Report with active orders as of 05/13/25, revealed Resident #1 had a Physician's Orders, dated 4/4/25, for Wanderguard bracelet daily elopement risk and Wanderguard check bracelet every shift for placement and functioning, replace bracelet if removed or not working properly elopement risk every shift. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 04, which indicated he was severely cognitively impaired. On 05/13/25 at 7:30 AM, an observation of the route from the area Resident #1 was located to the facility, revealed a busy four (4) lane highway with turning lanes and multiple traffic lights noted. There was heavy traffic flow to the facility, which was approximately one (1) mile from the location he was found. On 05/13/25 at 8:00 AM, during an interview, the Administrator stated that the facility's investigation into the Facility-Reported Incident (FRI) had been completed. She explained that a Quality Assurance and Performance Improvement (QAPI) meeting was held on the day of the elopement, and immediate corrective actions were implemented, including in-service training and a mock elopement drill conducted for each shift. The Administrator stated that based on interviews and the facility's investigation, it was determined that Resident #1 exited through the kitchen hallway via the loading dock door, which is located near the Dietary Manager's office. The resident accessed the area through an unsecured staff door leading into the kitchen. Resident #1 had previously been identified as an elopement risk and was wearing a wander guard device; however, the door used was not equipped with a wander guard sensor, although it did have a keypad lock. On 05/13/25 at 8:30 AM, during an observation, Resident #1's door to his room was closed. Upon entering, Resident #1 was standing with the assistance of a walker, and a staff member was seated in a chair nearby. Resident #1 appeared well-groomed and was alert and oriented to his name. A functioning wander guard device was noted on his right wrist, with the indicator light visibly flashing. On 05/13/25 at 8:55 AM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed she had been working on 05/09/25 when Resident #1 eloped from the facility. She explained that during her 7:00 AM morning rounds, she observed Resident #1 walking in the hallway without his walker. LPN #1 redirected the resident to return to his room to retrieve his walker, which he did. She described Resident #1 as pleasantly confused since his admission and stated that he had not yet received his morning medication. LPN #1 recalled that the last time she saw Resident #1, he was turning down Hall #4 toward the dining room. Later that morning, Dietary Aide #1 approached her to say the resident's daughter had called regarding a doctor's appointment, and that his walker was still in the dining room. LPN #1 instructed Certified Nursing Assistant (CNA) #1 to check the resident's room while she retrieved the walker. CNA #1 returned and reported that Resident #1 was not in his room. LPN #1, the CNA, and the dietary aide immediately began searching the facility. Within a few minutes, when they were unable to locate him, LPN #1 announced Dr. Wander over the intercom and notified the Administrator, Director of Nursing (DON), and the Staff Development Nurse. She stated Resident #1 had consistently worn a wander guard on his wrist, which was checked every shift by bringing the resident near the front door to ensure the alarm sounded and this was documented on the Medication Administration Record (MAR). She also noted that Resident #1 had expressed a desire to go home and had been observed multiple times attempting to open exit doors. Following the incident, Resident #1 was moved back to his original room, which is closer to the nurses' station, and he has since been placed on one-on-one supervision. On 05/13/25 at 9:30 AM, during an interview with the Director of Nursing (DON), she explained that Dietary Aide #1 was the first staff member to realize Resident #1 was missing. The DON stated that after the resident was returned to the facility, she and the Unit Manager/Registered Nurse (RN) #2 interviewed him. During the interview, Resident #1 reported that he had exited the building through the kitchen door, which led to a hallway connected to the loading dock. He then exited the facility through the door at the end of that hallway. On 05/13/25 at 10:25 AM, during an interview with Dietary Aide #1, she explained that on 05/09/25 at approximately 7:30 AM, she observed Resident #1 sitting at a table in the dining room. She stated the table was located three (3) tables away from the hallway leading to the dietary manager's office and an exit door. Resident #1 was seated with his walker beside him. As she delivered breakfast trays to Unit B, she turned around and noticed Resident #1 was no longer at the table, but his walker was still present. Dietary Aide #1 reported that she returned to the kitchen, and shortly afterward received a phone call from Resident #1's daughter, asking her to remind the nurse of the resident's scheduled doctor's appointment and ensure a change of clothes was sent with him. She went to notify LPN #1 and noted that Resident #1's walker remained in the dining room. LPN #1 retrieved the walker. Resident #1's breakfast tray had already been placed on the Unit B food cart, and since he had not eaten, staff assumed he had returned to his room. She recalled hearing a CNA inform the nurse that Resident #1 was not in his room. After being informed, she walked through the dining room, then down Unit A and made a full round back to Unit B, but did not see the resident. She notified the nurse and soon after heard the overhead announcement for a Dr. Wander. She then joined the search, looking in resident rooms and throughout the kitchen area. She stated she did not recall seeing the exit door to the loading dock open or ajar but believed it must not have been securely closed. On 05/13/25 at 10:50 AM, during an interview with CNA #1, she stated that on 05/09/25 she arrived to work late and did not see Resident #1 upon arrival. She recalled noticing his walker in the dining room, and LPN #1 asked her to check the resident's current room and the room he had recently been moved from, and he was in neither room. She reported back to the nurse that the resident was not in either location. CNA #1 stated that the nurse then began searching for the resident as well. When the resident could not be located, the nurse made a Dr. Wander announcement over the intercom, prompting all staff to assist in the search. CNA #1 explained that she helped search the entire facility, checking every resident room and even the closets. She confirmed that Resident #1 returned to the facility around 9:30 AM and appeared to be unharmed. On 05/13/25 at 11:05 AM, during a phone interview with Resident #1's daughter, she explained that her father had been residing at the facility for approximately one (1) month and had a diagnosis of Dementia. Since his admission, he frequently expressed a desire to go home and often asked how to get there. She stated that on the morning of 05/09/25 at approximately 7:30 AM, she called her friend who works in the facility's kitchen to ask her to remind the nurses and CNAs of her father's scheduled doctor's appointment at 9:00 AM. Her friend agreed to notify the nurse. Within ten (10) minutes of that phone call, Resident #1's daughter received another call informing her that her father was missing from the facility. She arrived around 8:00 AM and began assisting in the search. She also contacted her brother, who began searching the surrounding area. She initially believed her father may have walked up the street and would be found quickly. However, around 9:30 AM, her brother located their father on the opposite side of a busy highway, near a local fast-food restaurant. Resident #1 was walking through a grassy area adjacent to the road. She reported that although she does not know the exact route her father took, he later told her he exited through the kitchen door. She confirmed that her father had consistently verbalized his intent to return home, a behavior consistent with his Dementia diagnosis. Upon his return to the facility, the resident appeared tired but otherwise unharmed. On 05/13/25 at 11:20 AM, during a phone interview with Resident #1's son, he explained that on the morning of 05/09/25, his sister called to inform him that their father had left the facility unsupervised and staff were actively searching for him. He stated that he immediately left work to help locate his father. He looked at several locations he thought he may be and he began asking people in the area if anyone had seen an older man walking alone. One individual suggested he check along the highway and while driving in that area, he spotted his father walking in a grassy area on the opposite side of the busy four-lane highway. He was shocked that his father had managed to cross the highway safely. When he approached him, Resident #1 stated he was just trying to go home and explained that he had exited the facility through the kitchen. Shortly after, two nurses from the facility arrived and one of the nurses spoke with his father, who willingly got into the back seat of the vehicle and was transported back to the facility. On 05/13/25 at 11:30 AM, during a follow up interview with the DON, she explained that on the morning of 05/09/25, she was notified that Resident #1 was missing and that a Dr. Wander alert had been initiated prior to 8:00 AM. She arrived at the facility around 8:45 AM and joined the ongoing search for the resident. She confirmed that all other residents were accounted for. The DON stated that she personally inspected all exit doors to ensure they were functioning properly. She also conducted an exterior search of the facility, including walking around the building, stepping into nearby wooded areas while calling the resident's name, and checking the furniture store across the street. She did not observe any signs of a path having been taken. Staff members were provided with a photo of Resident #1 and were assigned to search various locations, including the adjacent hospital emergency room , stores, and surrounding businesses. When he was located and returned, the DON and the Unit Manager/RN conducted a full body audit on the resident. The RN documented the assessment in the resident's progress notes. Resident #1 was noted to be fully dressed in a white T-shirt layered with a long-sleeved shirt, long pants, and laced-up tennis shoes. The resident was wearing a clean brief with no signs of soiling. The DON reported that following the incident, all wander guard devices were inspected, and a review of all residents identified as at risk for elopement was completed with no concerns identified. She confirmed that wander guards are checked daily by the nursing staff and documented on the Medication Administration Record (MAR). In response to the incident, the facility added keypad alarms to all exit doors and conducted a Quality Assurance and Performance Improvement (QAPI) meeting. The DON also stated that elopement education was provided to all staff through in-services, and mock elopement drills were conducted on all shifts. Elopement books are maintained by Social Services and located at both nurses' stations. They contain resident photos, face sheets, and identification details. Social Services coordinated the mock drills, and Staff Development oversaw the in-service training. On 05/13/25 at 12:10 PM, during an observation and interview with RN #1, she explained that she and the MDS nurse were the staff members who located and returned Resident #1 to the facility on [DATE]. She stated that she arrived at the facility around 8:00 AM that morning and observed staff outside searching for the resident. After learning that Resident #1 had left the building, she began asking staff when he was last seen and what had occurred. She searched throughout the facility again, rechecking previously searched areas, including the kitchen and laundry rooms. RN #1 stated she and other staff also checked outside the building and surrounding wooded areas, but no clear path or trace of the resident was found. With other staff already out in their vehicles searching, she asked the second MDS nurse to accompany her to continue the search. They drove around the nearby apartment complex, streets, and highways. While driving down the major highway, RN #1 spotted Resident #1 walking in a grassy area near a local bank. She and the resident's son arrived at the location around the same time. Resident #1 was alert, oriented to his name, and entered the vehicle willingly. He was well-groomed and reported only that he was tired and trying to get home. Following the incident, RN #1 stated that Resident #1's care plan was updated, he was placed on one-on-one observation, and his room was changed to one closer to the nurse's station. She confirmed the facility held a Quality Assurance and Performance Improvement (QAPI) meeting, conducted in-services for all staff regarding elopement, and completed mock elopement drills that same day. She further explained that it was determined Resident #1 exited the building through the kitchen door at the loading dock. During the observation of the loading dock with RN #1, there was a sloped, paved, and covered loading dock area that opened into the rear parking lot and grassy yard. An uneven paved path extended around the building, bordered by dense woods, with the front of the building facing the main road. The surrounding area included a nearby hospital, a furniture store, and audible heavy traffic from a local highway. On 05/13/25 at 12:30 PM, during an interview with Social Services #1, she explained that she was not at the facility during the morning hours of 05/09/25 but was notified of the elopement prior to her arrival. She stated that while driving to the facility, she actively searched for Resident #1 along her route. She arrived around 8:55 AM and immediately joined staff in the search, both inside and outside the building. She confirmed that Resident #1 had previously been identified as an elopement risk and was wearing a wander guard at the time of the incident. Once the resident was located and returned to the facility, the DON notified all staff that the search was complete. Social Services #1 stated she is responsible for maintaining the facility's elopement books and performs random checks to ensure all information remains accurate. She noted there are three (3) elopement books kept in the facility. There is one (1) at each nurse's station and one (1) at the front office. She is the only staff member authorized to add or remove resident information from these books. She confirmed that she completed the post-trauma psychosocial assessment for Resident #1 upon his return, and no concerns were identified. On 05/13/25 at 12:50 PM, during an interview with RN #2, she reported that she was notified via text message on 05/09/25 regarding the elopement of Resident #1. She arrived at the facility at approximately 8:10 AM and immediately joined the search efforts. RN #2 stated she promptly notified the facility's Medical Director and Nurse Practitioner about the resident's elopement. While participating in the search, she also checked on other residents to ensure they were accounted for. Upon Resident #1's return to the facility, she and the Director of Nursing (DON) walked the resident to his room, performed a head-to-toe assessment, and assessed for pain. Resident #1 expressed that he was tired, and Tylenol was administered for comfort. Food was also offered. RN #2 confirmed that the assessment was documented in the resident's progress notes, and staff communicated with the resident's daughter regarding his return. On 05/13/25 at 2:00 PM, during an interview with Housekeeping #1, he stated that he was present at the facility on 05/09/25 at the time of Resident #1's elopement. He explained that he arrived at the facility around 5:45 AM and observed Resident #1 standing at the front door with his walker, appearing to attempt to exit the building. Housekeeping #1 noted there were no staff members nearby at the time, but the resident was wearing a wander guard, and the alarm activated when the door opened. He redirected Resident #1, who then walked back toward his room. He recalled having seen Resident #1 previously attempting to exit the facility through various doors, but assumed the wander guard system would alert staff. He did not recall seeing Resident #1 again that morning. Around 8:00 AM, he heard the overhead announcement for Dr. Wander, indicating a resident elopement. He immediately got into his vehicle and drove around nearby areas, including the hospital and near other roadways, in an effort to locate the resident. He was later informed via phone that Resident #1 had been found, and upon returning to the facility, the resident had already been brought back. The facility provided the following Corrective Action Plan: On 05/09/25 at 09:40 AM, RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries. On 05/09/25 a 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings. On 05/09/25 at 07:50 AM, all the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly. On 05/09/25 at 09:32 AM, Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly. On 05/09/25 at 09:40 AM, head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings. On 05/09/25 at 09:50 AM, Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident. On 05/09/25 at 09:55 AM, upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1;1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status. On 05/09/25 at 10:00 AM, a keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff. On 05/09/25 at approximately 10:00 AM, the Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility on Monday, 05/12/25. On 05/09/25 at 10:00 AM, Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning. On 05/09/25 at 11:00 AM, the Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director. On 05/09/25 at 11:00 AM, Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated on Friday and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement. On 05/09/25 at 11:00 AM the Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled for Friday, May 16, at 11:30 AM, as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye. On 05/09/25 at 01:00 PM, Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen. On 05/09/25 at 02:00 PM, the facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services. On 05/09/25 at 02:30 PM, we had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility. Starting on 05/09/25, Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place. A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident on Friday, May 9, 2025. Validation: The SA validated on 5/14/25, through interview and record review, that all corrective actions had been implemented as of 5/9/25, and the facility was in compliance as of 5/10/25, prior to the SA's entrance on 5/13/25.

Based on observation, staff and resident interview and record review, the facility failed to have sufficient nursing staff to meet the needs of residents as evidenced by failure to answer call lights and provide incontinent care in a timely manner for three (3) of 19 sampled residents, with the potential to affect all residents residing in the facility. (Residents #48, #87 and #23) Findings Include: Resident # 48 On 06/02/24 at 12:50 PM, an observation and interview of Resident #48, revealed a Certified Nurse Aide (CNA) entered the resident's room and turned off the resident's call light and exited the room. When the resident's room was entered, there was a strong unpleasant odor. Resident #48 stated the CNA turned off her call light and said that she would be back. The resident complained that this is something that happens frequently and it takes a long time for them to return to provide the requested care. The resident was unable to provide information regarding shifts and timing of the occurrences, adding that this happens on all shifts, at different times. On 06/02/24 at 1:16 PM, an observation revealed Resident 48's call light had been turned back on. At this time, the Director of Nurses (DON) entered the resident's room and came back out. During an observation and interview on 6/2/24 at 1:22 PM, revealed Licensed Practical Nurse (LPN) #2 entered the room of Resident #48 and came back out. LPN #2 stated that the resident was waiting on her CNA to come change her and explained the CNA was working her way to the resident's room, as she was the only CNA on the hall with 12 residents. During an observation at 1:50 PM on 06/02/24, revealed CNA #3 entered the resident's room and provided incontinent care. While observing the care, it was noted that the resident's incontinent brief was soiled and saturated with urine. On 06/03/24 at 3:15 PM, another observation of Resident #48 revealed that she was sitting up in her wheelchair waiting on assistance from staff. At this time, there was a strong smell or urine noted in the resident's room and in the hall outside the resident's room. On 06/03/24 at 3:35 PM, during an observation of incontinent care provided to Resident #48 revealed the resident's brief was saturated with urine. CNA #4 confirmed that the brief had leaked onto the wheelchair seat. Record review of the Face Sheet for Resident #48 revealed the facility admitted the resident on 04/17/18. The resident's diagnoses included Cerebral Infarction (Stroke), Type 2 Diabetes Mellitus and Hypertensive Heart Disease. Record review of the Quarterly Minimum Data Set (MDS), for Resident #48, with an Assessment Reference Date (ARD) of 04/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Resident #87 On 06/02/24 at 1:15 PM, in an interview with Resident #87, she complained of having to wait long period of time for staff to answer her call lights. Resident #87 reported this happens all the time. Resident #87 explained, the staff will answer the call light, and say they will tell someone, but will never come back and you will have to ring again, and someone will answer the light and say the CNA is on break and when she comes back, they will let her know. Resident #87 stated this happens during every shift, at all times of the shift. She stated she has even asked the nurses for assistance but has been told to wait for her CNA. A record review of the Face Sheet for Resident #87 revealed the facility admitted the resident on 09/13/24. The resident's diagnoses included Metabolic encephalopathy, Acute Kidney failure, and Hypertensive Heart Disease. A record review of the Quarterly MDS, for Resident #87, with an ARD of 03/11/24, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #23 On 06/02/24 at 2:13 PM, during an observation and interview with Resident #23, the resident revealed the facility is often short of staff and the wait time can be long when the call light is activated. The resident stated as recently as a week ago, there have been times when he has used his call light on the 11:00 PM to 7:00 AM shift and no one responded. On 06/02/24 at 2:30 PM, in an interview CNA #2 revealed at times the facility is short staffed. CNA #2 explained there have been days when there was only one CNA to cover an entire hall and the nurses will not assist the CNA's when they are short staffed. On 06/04/24 at 1:00 PM, during an interview with the DON, she explained she expects all residents to be changed in a timely manner, by any staff member who can provide the care, including nurses. On 06/05/24 at 4:00, during an interview with the Administrator, she explained she expects all nursing staff to provide care for residents and for no resident to wait long periods of time for care. Record review of the Face Sheet revealed the Resident #23 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Type 2 Diabetes Mellitus. Record review of Resident #23's Annual MDS, with an ARD of 4/2/24 revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on observations, interviews, record review, and facility policy review, the facility failed to honor resident's rights to have a choice of having bedrails for assistance with turning and bed mobility for two (2) of 19 sampled residents. Resident #54 and #78 Findings include: A record review of the facility's policy titled, Resident [NAME] of Rights, dated 01/23 revealed, Each resident has a right to a dignified existence, self-determination, and communication wish and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion including those rights specified herein . Resident #54 On 06/02/24 at 12:38 PM, during an interview with Resident #54, he revealed he wanted rails on his bed, but was told by the facility staff that he could not have rails due to the state's regulations. On 06/05/24 at 9:39 AM, during an interview with Resident #54, he explained he wanted his bed rails to assist him with turning and the rails give him some of his independence with moving around in the bed. Record review of Resident #54's Face Sheet revealed the facility admitted the resident on 9/14/22, with diagnoses that included Type 2 Diabetes Mellitus, Anemia, and Myalgia (muscle pain). Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/24, Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #78 On 06/02/24 at 1:50 PM, during an observation and interview with Resident #78, the resident was observed sitting up in his wheelchair. During the initial visit with Resident #78, the resident became loud and began cursing, saying what you can do is give me back my bedrails. He explained he was told the state is the ones who are responsible for taking away the bedrails. The resident reported he used the bedrails to help assist with turning and he wanted his bedrails back. Resident #78 explained the staff came in one day and just took his bedrails away. He further reported that he had asked and asked for them back, however, staff kept telling him the State will not allow him to have his bedrails. On 06/04/24 at 10:00 AM, during an interview with Certified Nurse Aide (CNA) #3, she stated the management team removed all bedrails, maybe over a month ago, but she is not exactly sure how long ago. Management told staff and residents, the State would not allow residents to have bedrails due to state guidelines. She also reported that management commented that the facility is a restraint free facility. She explained Resident #78 has been very mad and upset since his bedrails were removed and complains about not having the bedrails every day. On 06/04/24 at 10:32 AM, during an interview with Maintenance Director, he revealed the bedrails were taken off of all of the resident's beds in phases, which began the last week in April 2024 and ended 5/23/24. He explained the residents' bedrails were dismantled by order of the Administrator because they are a restraint free facility. On 06/04/24 at 5:00 PM, during an interview with the Administrator and the Director of Nurses (DON), both confirmed all resident's bedrails were removed from residents' beds. They stated the explanation given to residents and staff was that it was a state regulation. They confirmed that bedrails were not offered, and the need was not assessed per resident's choices or request. The Administrator and the DON acknowledged that this was a resident's rights issue, and the facility wishes to honor resident's rights and choices per each individual resident. They stated they plan to take the necessary steps to correct their previous action and evaluate each resident individually and restore bedrails, as appropriate, following the appropriate guidelines. On 06/05/24 at 10:20 AM, during an observation and interview of resident #78, the resident's bed still did not have any bedrails. Resident #78 remained upset about not having bedrails and voiced he wants them back. On 06/05/24 at 4:30 PM, the Administrator revealed the facility does not currently have a bedrail policy, only a restraint policy. Record review of Resident #78's Face Sheet revealed the facility admitted resident on 11/22/21, with diagnoses that included Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. Record review of Resident #78's Quarterly MDS with an ARD of 04/10/24, revealed BIMS Score of 09, which indicated moderate cognitive impairment. Section GG revealed Resident #78 required partial/moderate assistance with rolling left to right.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure timely incontinent care was provided for one (1) of two (2) residents observed for incontinent care. Resident #48 Findings include: Record review of the facility's policy titled, Resident [NAME] of Rights dated 01/23 revealed, Each resident has a right to a dignified existence . On 06/02/24 at 12:50 PM, an observation and interview revealed Resident #48's call light was on. At that time, a Certified Nurse Aide (CNA) entered the resident's room and turned off the light and exited the room. When the resident's room was entered, there was a strong unpleasant odor noted. Resident #48 reported she had told the CNA she needed to be changed. The resident stated the CNA turned the light off and said she would come back. The resident complained that it takes a long time for staff to answer her light, and when they do, they turn off the light and then it takes forever for them to come back to provide the care that had been requested. The resident then added that this happens on all shifts, at different times. On 06/02/24 at 1:10 PM, during an interview with Resident #48, she reported she is still waiting for someone to come clean her up. At 1:16 PM on 06/02/24, an observation revealed Resident #48's call light was again going off. The Director of Nursing (DON) entered the resident's room and came back out of Resident #48's room. On 06/02/24 at 1:22 PM, during an observation and interview revealed Resident #48's call light continued to go off. At this time, Licensed Practical Nurse (LPN) #2, entered the resident's room and came back out of the room. LPN #2 explained the resident was waiting on her CNA to come change her. LPN #2 explained the CNA was working her way to the resident, as there is one (1) CNA on the resident's hall with 12 residents. On 06/02/24 at 1:30 PM, during an interview with CNA #3, she explained it was not her that came out of resident's room earlier, but she will go and check on the resident. After CNA#3 came back from Resident #48's room, she explained the resident needed to be changed, so she will go ahead and change the resident. At 1:50 PM on 06/02/24, an observation revealed CNA #3 returned to the room of Resident #48 with supplies to provide incontinent care. While incontinent care was provided, an observation revealed the resident's incontinent brief was soiled and saturated with urine. On 06/03/24 at 3:12 PM, during an interview and observation of Resident #48, she was sitting in her wheelchair, wearing a gown and tee shirt. The resident reported she was waiting to get cleaned up. There was a strong smell of urine noted in the resident's room and in the hall outside the resident's room. At 3:25 PM on 06/03/24, during an interview with CNA #4, she explained she uses the pocket care guides for knowledge of individual resident care. She stated she has worked with Resident #48 previously, and the resident can stand and pivot and is incontinent of bowel and bladder. CNA #4 acknowledged Resident #48 does have periods of confusion, but she can make her needs known. At 3:35 PM on 06/03/24, during an observation of incontinent care provided for Resident #48, the resident's brief was saturated with urine. The resident's wheelchair was also wet. CNA #4 confirmed urine had leaked from the resident's brief onto the wheelchair seat. On 06/04/24 at 1:00 PM, during an interview with the DON, she explained she expects all residents to be changed in a timely manner, by any staff member who can provide the care, including nurses. On 06/05/24 at 4:00 PM, during an interview with the Administrator, she explained she expects all nursing staff to provide care for residents and for no resident to wait long periods of time for care. Record review of the Face Sheet of Resident #48 revealed the facility admitted resident on 04/17/18. The resident's diagnoses included Cerebral Infraction (stroke), Type 2 Diabetes Mellitus and Hypertensive Heart Disease. Record review of Resident #48's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Section GG revealed resident required substantial/maximal assistance with toileting and personal hygiene. Section H revealed Resident #48 is always incontinent of bowel and bladder.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure oxygen was delivered in a manner to prevent potential complications as evidenced by not following physician orders or facility policies related to oxygen therapy when a resident's oxygen tubing was not dated and there was no humidification provided for one (1) of 19 sampled residents. Resident #52 Findings Include: Record review of the facility's policy titled, Oxygen Therapy, reviewed 1/15, revealed, Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress . Equipment: . 2. Humidifier, if needed . Procedure: .8. Change tubing weekly. 9. Date tube when changed (weekly). On 6/02/24 at 1:02 PM, an observation and interview with Resident #52 revealed Resident #52 was sitting on her bed with oxygen flowing at 2 liters per nasal cannula. The oxygen tubing did not have a date on it, nor was there a humidifier bottle attached to the delivery system. Resident #52 stated she has been hospitalized two times due to shortness of breath. On 06/02/24 at 1:08 PM, in an interview with Licensed Practical Nurse (LPN) #1, she confirmed that there was no date on the oxygen tubing and there was no humidifier bottle attached to the oxygen. LPN #2 stated oxygen tubing should be changed and dated weekly. She stated if not, it could lead to an infection issue. LPN #1 explained that a humidifier should be attached, as it provides moisture and helps prevent the resident's nostrils from getting dry. On 06/04/24 at 3:46 PM, in an interview with the Director of Nurses (DON) she stated Resident #52 should have had a humidifier bottle attached to the oxygen delivery system. She stated the humidifier is used to prevent help keep the resident's nasal area moist. The DON stated the reason for changing tubing and dating it lets staff know when it was first applied. The DON stated The tubing is changed weekly to decrease the possibility of bacteria growing within the tubing. The DON explained that she expects staff to change a resident's oxygen tubing and to keep a humidifier on the oxygen. Record review of the Physician Orders for Resident #52 for the month of June 2024, revealed an order dated 5/6/24 Oxygen at 2 L/min (two/Liters/minute) per nasal bi-prong (cannula) continuously . An additional order dated 5/6/24 revealed Change Oxygen tubing weekly on Friday: Date and initial . Record review of Resident #52 Face Sheet revealed an admitted [DATE] with diagnoses that included Shortness of Breath and Acute respiratory failure with hypoxia. Review of Resident #52's Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) 5/13/24, revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. Section O was coded for oxygen.

Based on observation, facility policy review and staff interviews the facility failed to provide safe and secure storage of medications for one (1) of three (3) medications carts observed. Findings Include: Record review of the facility provided Medication Administration-General Guidelines dated 8/16, revealed, . 4. Medications are administered at the time they are prepared for each resident. Medications are not pre-poured .16 . No medications are left unattended on top of the cart. The cart is to be locked if not clearly visible and under the control of the personnel administering medications . On 11/09/23 at 8:20 AM, an observation revealed the medication cart outside room [ROOM NUMBER] was unattended, unlocked, and had three medication packets, containing four pills lying on top of the medication cart. There were no residents in the hallway. The medication packets lying on top of the medication cart were labeled Divalproex Sprinkles mcg (micrograms) 2 CAPSULES, Losartan 50 MG (milligrams) one (1) TABLET, Olanzapine 7.5 MG one (1) CAPSULE. On 11/09/23 at 8:24 AM, an interview with Licensed Practical Nurse (LPN) #1 she stated she had gone into a resident's room to obtain their vital signs and left the medication cart unattended and unlocked with a Resident's medications lying on top of the cart. LPN #1 confirmed that the medications should not have been left out on top of the cart but had no explanation; she stated, I just went to get the vital signs. On 11/09/23 at 8:35 AM, during an interview with the Director of Nurses (DON), she stated that medication carts were never to be left unattended and unlocked and that medications were never to be left on top of an unattended medication cart. The DON confirmed that the medications were not appropriately stored or secured. She stated that the facility policy was that all medications were to be stored and secured in a locked medication cart or medication room. The DON commented that medication errors could result from unsecured medications if a resident were to take the unsecured medication. On 11/09/23 at 12:00 PM, an interview with the Administrator revealed that nurses were expected to secure all medications and that leaving medications lying on top of an unattended, unlocked medication cart did not secure medications.

The State Agency (SA) conducted a complaint investigation (CI), Cl MS # on 6/9/2021 through 6/10/2021 and substantiated CI MS # related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 5/31/2021 at approximately 5:54 AM. Resident #1 was away from the facility and unsupervised for approximately one (1) hour 28 minutes. The facility staff were unaware of Resident #1's absence until the breakfast trays were being delivered and discovered that Resident #1 was not in her room. The facility completed a facility wide search and began to search the surrounding roads. The Resident was located at 7:26 AM by Maintenance Staff #1 approximately 0.5 miles from the facility standing at the corner of a major intersection. Resident #1 was returned to the facility by Register Nurse (RN) #2 and assessed for any signs and symptoms of injury or distress without concerns. The facility's immediate investigation revealed Resident #1 exited the facility through the front door when Dietary Aide #1 entered the building and held the door open for the Resident #1 to exit the door. Resident #1 was placed on 15 minute checks until her primary physician arrived at the facility and completed a physical exam and determined there was no harm to Resident #1 while away from the facility and unattended. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 6/9/2021 and existed at: 42 CRF(S): 483.25 (d)(1)(2)- Free of Accidents, Hazards/Supervision/Devises (F689). The facility's failure to provide adequate supervision to prevent the elopement for Resident #1, who was diagnosed with Alzheimer's Disease and Dementia with Behavioral Disturbance, allowed Resident #1 to exit the facility unnoticed and unsupervised until Maintenance Worker #1 found Resident #1 standing at the corner of a major intersection, approximately 0.5 miles from the facility. This situation placed Resident #1 and other residents with diagnoses for Alzheimer's and Dementia with Behavioral Disturbance at risk for elopement and the likelihood for serious injury, harm, impairment, or death. Based on the facility's implementation of corrective actions on 5/31/2021, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 6/1/2021, prior to the SA's entrance on 6/9/2021. The SA notified the facility's Administrator of the PNC IJ and SQC on 6/9/2021 at 3:35 PM. At the time of the investigation the facility had a census of 80 and held a license of 100 beds. Based on interviews, observations, record review, facility investigation review and policy review the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility on 5/31/2021 at 5:54 AM. The facility staff did not know that Resident #1 was off the facility grounds until breakfast trays were being delivered and Resident #1 was not in her room. This concern was identified for one (1) of four (4) residents reviewed for diagnoses of Alzheimer's Disease and Dementia (Resident #1). Findings include: Review of the facility's policy, Missing Resident/Elopements, updated 7/18, revealed, it is the policy of this facility that all Unit Charge Nurses are responsible for knowing the location of their residents. On 6/9/2021 at 9:00 AM, in an interview with the facility's Administrator, she stated that the facility admitted Resident #1 on 10/19/20. Upon admission, the resident had been assessed by the Director of Nursing (DON) and was not deemed an elopement risk. She further stated that Resident #1 had never exhibited any wandering behavior and had never attempted to exit any of the doors. The facility's investigation revealed the Administrator had interviewed Dietary Aide #1 on the morning of Resident #1's elopement and provided the SA with a signed statement from Dietary Aide #1. The facility's investigation confirmed that Dietary Aide #1 opened the facility's front door on May 31, 2021, at 5:54 AM and held the door open for Resident #1 to exit the facility. The investigation revealed Dietary Aide #1 explained as she drove into the facility parking lot at 5:50 AM, she noticed a lady in the parking lot dressed in medical scrubs and a lab jacket. She stated Dietary Aide #1 explained that she also noted a medical cart beside the car door. Dietary Aide #1 said as she keyed her code into the door, opened the door and entered the facility, a lady was standing in the hallway and approached the door. Dietary Aide #1 stated that she noted the lady to be clean and neatly dressed wearing pants, a shirt, jacket, and a face mask. Dietary Aide #1 explained as she entered the building, the lady walked out the door. Dietary Aide #1 had told the Administrator she believed the lady to be with the person outside in the parking lot. The investigation revealed when the nursing staff realized Resident #1 was missing and called a Dr. Wander, Dietary Aide #1 told Licensed Practical Nurse (LPN) #1, she thought the missing resident had gone out the front door earlier that morning when she opened the door. The investigation revealed LPN #1 explained to Registered Nurse (RN) #2 that a Dietary Aide had said that she thinks she had let the Resident out of the building earlier that morning and the staff began to search the facility's grounds. It was during that time that Housekeeping Staff #1 and Maintenance Staff #1, got into their vehicles and begin to drive the surrounding area in search of the missing resident. The Administrator stated the facility's investigation revealed Resident #1 was located at approximately 7:22 AM, standing at the corner of a major intersection approximately 0.5 miles from the facility. RN #2 reported that when Maintenance Staff #1 called and said that he had located the Resident, she got into her car, drove to the area, approached Resident #1, and asked her to ride with her back to the facility. RN #2 stated that Resident #1 walked to the car, got in and rode back to the facility with RN #2 without incident. RN #2 told the Administrator that during the ride back to the facility, Resident #1 was pleasant, her voice was calm, and her facial expression were relaxed. Once the Resident was safely returned to the facility, the Resident was examined by RN #2. RN #2 reported that there were no visible changes noted to Resident #1's balance or gait and no injuries were noted. At 7:50 AM, RN #2 stated that she notified Resident #1's primary physician of the elopement, with no visible signs of injury. RN #2 also told the Administrator that she had notified Resident #1's daughter of the incident. The Administrator stated Resident #1's physician arrived at the facility around noon and assessed Resident #1. She further stated that when the doctor assessed the resident, he found her to be alert, in no distress and without injuries. Upon completion of her investigation, the Administrator stated that the allegation of Resident #1 walking out of the building was substantiated, and she contacted the State and Attorney General's office and reported the incident. The Administrator stated that they held a Quality Assurance and Performance Improvement (QAPI) meeting and began to put corrective actions into place. The Administrator stated the facility began to have additional elopement drills and began in-servicing all employees on elopement and supervision of residents. The Administrator stated that she had suspended Dietary Aide #1, pending investigation, but after the day of the elopement, Dietary Aide #1 never returned to the facility. The Administrator provided the State Agency (SA) with copies of the statements received regarding the investigation, the sign-in page of the QAPI meeting that was held on the afternoon of the incident to discuss the incident and steps that needed to be taken to prevent this from happening again. The Administrator stated that during the in-services held immediately after the incident, the importance of employees stopping anyone attempting to exit a door and have them identify themselves prior to allowing them to exit. On 6/9/2021, at 9:30 AM, the SA walked throughout the facility. No residents were noted to be wandering into other rooms or common areas. There were no residents seen standing at exits or attempting to exit the building. The staff were observed assisting residents with morning care. No call lights were noted to be unanswered and there were no foul odors noted. Signs were noted on both sides of the front door that reminded staff not to allow residents to exit the doors unattended. On 6/9/2021, at 9:45 AM, Resident #1 was observed sitting up in her bed. During a brief interview, it was noted that the Resident was only oriented to person. The Resident was very pleasant and appeared well groomed. She was unable to recall any information regarding her whereabouts and stated that she lived in another city and was only at the facility until they could find out what was wrong with her and then she would be going back home. On 6/9/21 at 10:00 AM, in an interview with Housekeeping Staff #1, he revealed that on the morning of 5/31/21 when he came to work the nurses had already called Dr. Wander for Resident #1. He stated that the nurses were outside looking, so he immediately got into his vehicle and started driving toward the local hospital. He stated that he got a call saying that the Resident had been found and he turned around and drove back to the facility. He stated that he has never seen Resident #1 wandering around the building or standing at the doors looking outside like she wanted to go out the door. Housekeeping Staff #1 stated he is responsible for conducting the elopement drills and they have them every quarter. He stated on the day of the elopement, they had a meeting with the staff, and he had held an elopement drill. He further stated after Resident #1's elopement, all the employees, including himself, had to attend an in-service on elopement and supervision before they were allowed to work. On 6/9/21 at 11:10 AM, in an interview with LPN #1, she stated that on the morning of 5/31/21, she was working on Unit A when RN #2 walked onto Unit A asking if she had seen Resident #1. She stated that she had told RN #2 that she had not seen Resident #1 that morning. At that time, RN #2 called Dr. Wander for Resident #1. LPN #1 stated that not long after Dr. Wander was called, Dietary Aide #1 approached her and stated that she was afraid that she had let Resident #1 out when she came in that morning for work. LPN #1 said that after helping the Certified Nursing Assistants (CNA's) search the rooms, she and RN #2 went outside and started searching the grounds. She further stated that she had never noticed Resident #1 wandering or attempting to get out of a door. LPN #1 confirmed that she had attended an in-service about elopement and supervision and took part in an elopement drill after Resident #1 eloped before she was allowed to work. On 6/9/21 at 11:20 AM, in an interview with Certified Nursing Assistant (CNA) #1 when asked by the State Agency (SA) to recall the events that occurred the morning on 5/31/21 when Resident #1 eloped, she stated she was working on Unit A when LPN #1 asked if she had seen Resident #1 that morning. CNA #1 stated that she told LPN #1 no. She further stated that it was at that time that Dr. Wander was called, and all the staff started going from room to room searching for the Resident. CNA #1 stated said that she has worked on Unit B in the past and had assisted with the care of Resident #1, but she never recalls the Resident wandering in the halls or attempting to leave the building. CNA #1 stated that she had been required to attend an in-service about elopement and had been involved in an elopement drill after Resident #1 eloped prior to being allowed to work. On 6/9/21 at 11:35 AM, Maintenance Staff #1 was interviewed regarding the elopement of Resident #1 on 5/31/21. He explained that he had just reported to work that morning and was working out back when he heard Resident #1 could not be located. He stated his instinct was to get in his truck and start driving to look for her. He said he saw her standing at the corner of a major intersection, so he immediately called RN #2. He further stated that he parked his car and just watched the Resident because he was afraid if he approached her, it would scare her. He said that the Resident was not attempting to cross the road, she was just standing there, so he watched her and waited for RN #2 to come and get Resident #1 and take her back to the facility. Maintenance Staff #1 stated that he had never seen Resident #1 wandering around the building or standing at doors attempting to get out. He said that the only time he had ever seen her do anything away from her hall was when she played BINGO. Maintenance Staff #1 confirmed that he had been required to attend an in-service about elopement and had taken part in an elopement drill right after Resident #1 eloped. On 6/9/21 at 11:50 AM, in an interview with RN #2, Staff Development Coordinator, she said that she was working on the 7-3 shift the morning of 5/31/21 when Resident #1 eloped. She stated that when the CNAs were passing out the breakfast trays, a CNA told her Resident #1 was not in her room. They looked across the hall in the room of Resident #1's friend to see if she was in there, but she was not. RN #2 stated that she walked over to Unit A and asked LPN #1 if she had seen Resident #1. RN #2 said that when LPN #1 said that she had not seen the resident, she activated Dr. Wander, and everyone stopped what they were doing and began to search the rooms for Resident #1. She stated that she and LPN #1 went outside and began to search the grounds. Maintenance Staff #1 got in his truck and within a few minutes, he called her stating that he had located Resident #1. She said that she got into her car and went to the corner where the Resident had been located and assisted Resident #1 into her car and returned to the facility. RN #2 further said that Resident #1 stated that she had been for a walk and did not resist her effort to walk with her to her car and drive back to the facility. RN #2 stated that she did not ever recall seeing Resident #1 anywhere except in her room, across the hall in her friend's room or at the nursing station. Since the elopement, RN #2 stated that all employees had been in-serviced on elopement, supervision, and the importance of identifying anyone attempting to exit the building prior to opening the door and allowing them to exit. RN #2 said that employees were required to attend the in-services and elopement drills prior to being allowed to report to work. On 6/9/2021 at 12:15 PM, the Administrator provided the SA with a copy of the QAPI sign-in sheet, copies of the elopement drills and in-services that were held on were held in the six (6) months preceding Resident #1's elopement and copies of the elopement drills and in-services on supervision and elopement that were conducted post the 5/31/2021 elopement. The Administrator also provided copies to the SA of a staffing grid for review, the facility's Missing Resident/Elopement Policy, and the facility's investigation notes that were completed after the elopement. On 6/9/2021 at 1:45 PM, SA attempted to call Dietary Aide #1, but was unable to reach. On 6/10/21 at 11:15 AM, in an interview with the DON, she stated that the facility did not have a separate policy on observation. She stated that they do not have documentation of the times prior to the elopement that the nursing staff had visual contact of Resident #1 on the morning prior to her elopement. She stated that unless residents have been identified as an elopement risk, the staff are not required to document times of visualization. Record review of the QAPI sign-in sheet revealed that all department heads and the Medical Director were in attendance for the QAPI meeting held on 5/31/2021 at 4:00 PM. Record review of Resident #1's Face Sheet revealed that Resident #1 was admitted on [DATE]. Resident #1's medical diagnoses included Dementia with behavioral Disturbance, Major Depression, Alzheimer's Disease, and Hypertension. Record review of Resident #1's Admission Risk of Elopement Evaluation completed on 10/19/2020, revealed that the Resident #1 was not at risk for elopement and Resident #1 was not care planned for wandering behavior. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five (5), which indicated severe cognitive impairment. Section E of the Quarterly MDS revealed that Resident #1 had an absence of wandering behavior. Review of the weather report provided by the Administrator obtained during her investigation, stated that the temperature during the time of Resident #1's elopement had been approximately 65 degrees Fahrenheit with no rain noted. The SA verified the report was correct at https://www.timeanddate.com. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 6/9/2021: Resident #1's incident was taken to Quality Assurance and Performance Improvement (QAPI) on 5.31.21 at 4:00p.m. The QAPI members in attendance were the Medical Director, Executive Director, Director of Nursing, Social Services Director, Business Office Manager, Unit A Manager, Unit B Manager, Certified Dietary Manager, Activity Director, Staffing/Central Supply, Human Resources, Maintenance Director, Registered Nurse, Infection Preventionist/Staff Development, Medical Records, Restorative/Minimum Data Set (MDS) Licensed Practical Nurse (LPN), Treatment Nurse, and the Director of Admissions. The facility took actions to ensure the provision of adequate supervision to meet the resident's needs. This was evident by in-services, re-assessments, elopement drills, wander guard checks, and audit tools. The Maintenance Assistant located Resident #1 on 5.31.21 at 7:22 a.m. Resident #1 was located at the corner of [NAME] Drive and [NAME] Road extension. After locating Resident #1, the Maintenance Assistant remained parked with visual observation of Resident #1 until the Registered Nurse (RN) arrived at 7:26 a.m. and transported Resident #1 back to the facility. Resident #1's assessment was completed immediately upon return to the facility by the Registered Nurse (RN) with no adverse findings. Resident#1's Care Plan and Pocket Care Guide was updated on 5.31.21 by the Unit Manager to reflect elopement risk and presence of wander guard bracelet. A wander guard bracelet was applied to Resident #1 on 5.31.21 by the Registered Nurse (RN). Resident #1's location was monitored no less than every 15 minutes until assessed by the Physician on 5.31.21 at noon. The assigned nurse, Certified Nursing Assistant (CNA), and/or designee documented every 15-minute visual checks on Resident #1's Resident Location Monitoring Sheet with no significant changes. Resident #1's assigned nurse conducted a visual check of the wander guard bracelet daily on 5.31.21 every hour with documentation of the intervention on the Electronic Medication Administration Record (E-MAR). Resident #1's wander guard bracelet was checked by the assigned nurse every shift for proper placement and functioning with documentation on the E-MAR, daily for each shift. The Maintenance Supervisor initiated testing of the Wander Guard System of the building on 5.31.21 daily for proper functioning for two (2) weeks, then three (3) times a week for one (1) week, then weekly. The Social Service Director updated on 5.31.21 the Elopement Books and initiated an Elopement Alarm Drill on all shifts with employees. Mandatory Elopement Alarm Drills were conducted weekly by the Social Service Director for four (4) weeks, then monthly for one (1) month, then quarterly. The Regional Nurse Consultant on 5.31.21 conducted a mandatory in-service with the Executive Director (ED) and Director of Nursing (DON) on HART review and checklist. The Executive Director on 5.31.21 conducted a one on one (1:1) in-service regarding Validating Identity of Person Prior to Opening the Entrance Door and Allowing an Unknown Person to Exit the Building; Abuse and Neglect, Prevention, and Reporting; Elopement/Alarm Drill Protocol with the dietary worker who failed to verify the identity of Resident #1, to prevent an elopement, on 5.31.21. The Staff Development Coordinator (SDC) initiated mandatory in-service on 5.31.21 on: Validating a Person's Identity Before Opening the Facility's Front Door, Elopement Alarm Drill Protocol, and Abuse and Neglect, 6.1.21 in-service on Resident Daily Observation. No staff were allowed to work until in-serviced. The Dietary Manager (DM) initiated on 5.31.21 an in-service on the Importance of Knowing Residents and Keeping Them Safe. On 5.31.21, the Unit Managers and Director of Nursing (DON) conducted a 100% head count location audit to ensure all residents were accounted for with no adverse findings. The Director of Nursing and/or designee initiated HART Team audits of Clinical Notes and the 24 hour reports to ensure that any residents that exhibit any wander risk behaviors were properly assessed with the appropriate interventions put in place to minimize any potential risk. This was audited five (5) days a week beginning 5.31.21 for two (2) weeks, then three (3) days a week for two (2) weeks, then weekly. On 5.31.21, 100% audit on residents' elopement assessment were completed by Unit A and Unit B Managers with no adverse findings. The Dietary Manager (DM) toured the facility on 5.31.21 with the dietary staff introducing them to ambulatory residents and resident's mobile via wheelchair capable of wheeling themselves who prefer to eat in their rooms. A screener was scheduled from 5:30am - 6:30am daily in the front lobby. The duties included validating a person's identity before opening the facility's front door. A Dr. Wander Post Test was initiated on 5.31.21 by Social Services Director and/or Executive Director to ensure verbalization and observation of Elopement Alarm Drill Protocol. The Executive Director initiated audits of employees for verbalization and/or observation of Elopement Alarm Drill Protocol daily for one (1) week, then once a week for four (4) weeks, then monthly for one (1) month, then quarterly. The State Agency (SA) validated the facility's corrective action on 6/10/21: The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance and Performance Improvement (QAPI) meeting on 5/31/2021. The actions taken to ensure the provision of adequate supervision to meet Resident #1's needs were verified was evidenced by verification of the in-services, re-assessments, elopement drills, wander guard checks, and audit tools. The SA verified that Maintenance Staff #1 had located Resident #1 and parked at the vicinity with visual observation of Resident #1 until RN #2 arrived at 7:26 AM and transported Resident #1 back to the facility. Resident #1's assessment was completed immediately upon return to the facility by RN #2 and no adverse findings were identified. The SA verified that Resident #1's Care Plan and Pocket Care Guide was updated on 5/31/2021 to reflect elopement risk and presence of wander guard bracelet. The SA verified that the wander guard bracelet was applied to Resident #1's wrist and that Resident #1's location was monitored no less than every 15 minutes until assessed by the Physician on 5/31/2021 at noon through review of documentation. The SA also validated through Resident #1's Electronic Medical Record (EMAR) that the hourly visual checks, shift checks for function and placement, and documentation was completed for Resident #1's wander guard. Record review revealed the Maintenance Supervisor had initiated the two (2) week daily testing of the Wander Guard System of the building for functioning on 5/31/2021. Through interview on 6/9/2021, the Maintenance Supervisor verified that after the two (2) weeks, he was scheduled to check functioning three (3) times a week for one (1) week, and then weekly. The SA validated that the Social Services Director had updated the Elopement Books and initiated an Elopement Drill on all shifts with employees. The Maintenance Supervisor was assisting with these drills, and he was able to verify that the facility had conducted the drills as planned. The SA validated through interviews and sign-in sheets that on 5/31/2021, the Regional Nurse Consultant conducted a mandatory in-service with the Administrator and DON on Health Assessment Review Team (HART) review and checklist, the Administrator conducted one on one (1:1) in-services with the Dietary Aide, and the Staff Development Coordinator (SDC) initiated mandatory in-services beginning on 5/31/21 as planned. The SA validated that the in-services had been conducted as documented by review of sign-in sheets and with interviews with six (6) CNA's, seven (7) LPN's, one ()1 RN, three (3) Housekeeping Staff, one (1) Maintenance Staff, one (1) Receptionist, one (1) Medical Records Staff, and one (1) Dietary Staff. SA validated through record review and staff interviews the Unit Managers conducted a 100% head count location on all residents, audits of the Clinical Notes and 24 -hour reports were being conducted, 100% audit on residents' elopement assessment were completed, the dietary staff toured the facility, there was a screener scheduled from 5:30 AM - 6:30 AM in the front lobby, and confirmation of Elopement Alarm Drill Protocol was being conducted as planned.