Every finding on record at Civic Center Health and Rehabilitation, LLC

Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's policies titled Cleaning Schedules, Cleaning of Miscellaneous Equipment and Utensils, and Insect and Rodent Control, the facility failed to prevent the potential for cross-contamination and foodborne illness as evidenced by: The kitchen floor was dirty and had grease build up; The stove had grease build up present; The deep fryer had grease and food build up; The drain near the deep fryer had water and grease on top of the drain; Chipping paint was observed on the ceiling directly above clean pots and pans; and A serving tray with an unknown liquid brown substance was observed in the walk-in cooler. This had the potential to affect all residents who received meals from the facility's kitchen. Findings include: A review of 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, documented: .4-204.120 Equipment Compartments, Drainage. EQUIPMENT compartments that are subject to accumulation of moisture due to conditions such as condensation, FOOD or BEVERAGE drip, or water from melting ice shall be sloped to an outlet that allows complete draining .6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair .6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . A review of a policy titled Cleaning Schedules documented .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. A facility policy titled Cleaning of Miscellaneous Equipment and Utensils with an effective date 09/03/2019, documented: .14. Floors: . Mop floor using disinfecting detergent solution, as needed, and at least once daily . Housekeeping services will deep-clean the dietary floors at least quarterly . 19. Deep Fat Fryer: . b. Weekly: Fill Fryer with detergent solution Scrub fryer, both inside and outside Drain detergent solution from fryer . Rinse Wipe dry . A facility policy titled Insect and Rodent Control with an effective date of 002/01/2002 documented: .PROCESS: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. On 03/18/2024 at 4:45 PM during initial kitchen inspection with the Dietary Manager (DM), the floor near the three compartment sink, dishwashing area, and the entire floor was found to be unclean, with an unidentified black substance present. The DM said, they had scheduled a pressure washing of the floor later in the week. Inside the walk-in cooler, a soiled pan containing an unknown brown liquid substance was noticed. The DM was unaware of why the pan was stored in the walk-in cooler and said, it should be removed. Additionally, a build-up of grease and cooking residue was observed on and around the deep fryer. The drain adjacent to the deep fryer had stagnant water and grease accumulating near its top. The DM acknowledged that the drain was not functioning properly and had recently been sealed off. The DM did not know the reason behind the pooling water and grease on the top of the drain. Furthermore, grease buildup was detected on the back of the stove and stove knobs, while peeling paint was observed above the hanging pots and pans. During a revisit to the kitchen on 03/21/2024 at 11:29 PM, chipping/peeling paint above the hanging pots and pans was observed. The DM said, the ceiling had been in that condition for over a year. Additionally, there was grease buildup and food debris around the deep fryer, while the stove and stove knobs also had grease accumulation present. On 03/22/2024 at 10:05 AM, an interview was conducted with the Dietary Manager. The DM said. there should be no grease accumulation on the deep fryer, pipes near the deep fryer, stove, and stove knobs. The DM said, the floor should be kept clean and it was power washed on 03/19/2024 (Tuesday) and prior to that, the last deep cleaning of the floor had taken place six months ago. The DM said, the cleaning schedule for the kitchen included daily mopping of the floor. The DM said, the pan observed in the walk-in cooler during the initial tour should not have been there and was removed. The DM said, there should not be chipping paint above the pots and pans and it had been that way for at least one year. The DM said, the drain near the deep fryer should not have water and grease on top of it and a company that recently sealed the drain would be contacted. The DM said, the kitchen should be clean because it could attract bugs, cause the food to be bad and potentially make the residents sick.

Based on observations, interviews, and review of facility policies titled, Hand Hygiene, LAUNDRY STORAGE, COLLECTION & TRANSPORT, and LAUNDRY - HANDLING CLEAN LINEN, the facility failed to ensure staff provided care to residents and handled supplies and linen in a manner to prevent the possibility for cross-contamination of residents and their environment. On 03/19/2024 Certified Nursing Assistant (CNA) #7 touched the floor and without performing hand hygiene touched Resident Identifier (RI) #53. On 03/19/2024 Nursing Assistant (NA) #8 took supplies from RI #10's room to RI #16's room, and touched soiled barrels and then clean linen for RI #9 and RI #74 without performing hand hygiene. The wipes taken from room to room were also placed on the clean linen. Laundry Staff (LS) #10 was observed on 03/19/2024 delivering clean cloths to RI #19, RI #34, and RI #77, from an uncovered cart without performing hand hygiene. Dirty laundry placed in the laundry chute on 03/21/2024 was not in a bag. On 03/21/2024 Medication Technician (MT) #6 was observed removing gloves during Medication Administration for RI #3 without performing hand hygiene. This deficient practice had the potential to affect 9 of 19 residents observed for infection control. Findings include: Review of a facility policy titled Hand Hygiene with an effective date of 06/11/2020 revealed: . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. III. Hand Hygiene . Before and after assisting a resident/guest with personal care . Upon and after coming in contact with a resident/guest(s) intact skin . After handling soiled equipment . After removing gloves . Review of an undated facility policy titled LAUNDRY - HANDLING CLEAN LINEN revealed: . POLICY: After washing, cleaned/dried textiles, fabrics and clothing shall be folded for transport, distribution and storage by methods that ensure their cleanliness until used. PROCEDURE: . All linen shall be transported from the Laundry in a clean, covered linen cart with a solid bottom. The Laundry staff shall wash their hands before handling clean linen. Review of an undated facility policy titled LAUNDRY -STORAGE, COLLECTION & TRANSPORT revealed: . POLICY: All linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms to other patients and areas. If laundry chutes are used all linens should be bagged. Clean linens shall be transported to patient care areas by use of covered carts with solid bottoms by the Laundry staff. RI #53 was admitted to the facility on [DATE]. On 03/18/2024 at 5:07 PM CNA #7 entered RI #53's room with a food tray, placed it on the bedside table, bent down on the floor on her hands and knees, touching the floor with both hands to look for the bed remote control under the bed. CNA #7 then got up from the floor and without washing or sanitizing her hands or the bed remote, lifted the head of the bed up, put down the remote on the side of the bed, put her hands on RI #53, assisted the resident to turn around to the bedside, and put shoes on RI #53. On 03/18/2024 at 05:46 PM CNA #7 was asked about washing and sanitizing her hands. CNA #7 stated, she was supposed to wash or sanitize her hands before providing care. CNA #7 stated, she got down on her hands and knees to look for the bed remote. CNA #7 said, she assisted RI #53 up to the side of the bed without washing her hands. CNA #7 stated, after touching the floor she should have washed or sanitized her hands. CNA #7 stated, there was a risk of contamination since she did not wash or sanitize her hands before touching RI #53. RI #10 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #16 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #74 was admitted to the facility on [DATE] and readmitted on [DATE]. On 03/19/2024 at 10:10 AM NA #8 was observed coming out of RI #10's room with bath wipes in her right hand and with her left hand she pushed the yellow dirty linen barrel and the gray trash barrel down the hall in front of RI #9 and RI #74's room. CNA #9 in RI #9 and RI #74's room and asked NA #8 for a pillow case for the residents. NA #8 let go of the barrels, lifted the clean linen pink cover up, set the bath wipes from RI #10's room on the clean linen, and handed clean pillow cases to CNA #9. NA #8 then picked up the bath wipes and a box of gloves in her right hand, pulled the pink cover back over the linen on the cart, and continued pushing the yellow and gray barrels down the hallway. On 03/19/2024 at 10:13 AM NA #8 stated, before handling clean linen hands must be washed. NA #8 stated, the yellow and gray barrels were considered dirty. NA #8 stated, CNA #9 asked for pillowcases for RI #9 and RI #74. NA #8 stated, she did not wash or sanitize her hands after touching the gray and yellow barrels. NA #8 stated, she did not know why she did not wash or sanitize her hands before touching the clean linen. NA #8 stated, there was a risk of cross-contamination by touching the pillowcases after touching the dirty yellow and gray barrels. NA #8 stated, she should have washed her hands before touching the clean linen cart. NA #8 stated, she cared for 13 residents on 03/19/2024. On 03/19/2024 at 10:16 AM NA #8 was observed taking the bath wipes and the box of gloves into room RI #16 and closed the door. On 03/19/2024 at 10:23 AM CNA #9 confirmed the pillowcases she asked NA #8 for, were used for RI #9 and RI #74. On 03/19/2024 at 10:49 AM a follow up interview was conducted with NA #8 and she was asked about what she did. NA #8 stated, she brought the gloves and the package of wipes into RI #10's room and put them on the nightstand next to RI #10's bed. NA #8 stated, she would consider the package of wipes and the box of gloves dirty after being in RI #10's room. NA #8 stated, she put the package of wipes and the box of gloves on the clean linen after leaving RI #10's room. NA #8 stated, she did not know why she put the package of wipes and box of gloves on the clean linen. NA #8 stated, there would be a risk of cross contamination when putting the package of wipes and the box of gloves on the clean linen. RI #19 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #34 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #77 was admitted to the facility on [DATE]. On 03/19/2024 at 11:20 AM Laundry Staff (LS) #10 was observed passing out clean laundry from an uncovered gray cart. LS #10 went from room to room opening resident room doors and closet doors to deliver hanging cloths to RI #19, RI #34, and RI #77 without washing or sanitizing her hands between rooms. On 03/19/2024 at 11:26 AM LS #10 was asked about what she was doing. LS #10 stated, she was passing clean laundry to the residents. When asked about covering the laundry cart, LS #10 said, she only covered it when she was outside. When asked about washing her hands LS #10 said, she only washed her hands when she came into the building. LS #10 stated, the facility policy was to wash or sanitize hands before entering a resident's room. LS #10 stated, the linen uncovered had the risk of being contaminated. On 03/21/24 at 03:23 PM the HLS was asked about hand hygiene and delivery of clean laundry to resident rooms. The HLS stated, staff were to wash their hands before entering and when exiting a room. The HLS stated, there was a risk of cross-contamination if staff did not wash hands when entering a room. The HLS stated, clean laundry should be transported covered with a white clean blanket to prevent cross-contamination. On 03/21/2024 at 03:02 PM an observation was made with Housekeeping/Laundry Supervisor (HLS) of loose unbagged towels in the dirty laundry bin under the laundry chute. HLS stated, sometimes staff threw one towel or one wash cloth down the laundry chute not bagged. During the observation several towels and a purple gown came down the laundry chute unbagged. On 03/21/24 at 03:23 PM the HLS was asked about what had been observed and she stated, the dirty laundry put in the laundry chute should always be bagged and it should not be carried on the hall without being in a bag because it could cause cross-contamination if the dirty laundry was not in a bag. RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. On 03/21/2024 at 08:00 AM Medication Technician (MT) #6 was observed during Medication Administration wearing a glove to handle medication, then she removed and disposed of the glove without washing or sanitizing her hands. On 03/21/2024 at 09:06 AM MT #6 stated, hands should be sanitized before and after putting on or taking off gloves. MT #6 stated, she did not sanitize her hands when she used gloves during medication administration for RI #3. MT #6 stated, there would be a risk of cross contamination when not washing or sanitizing hands before and after glove use. On 03/22/2024 at 11:15 AM the Infection Preventionist (IP) was asked about infection control practices. The IP stated, staff should wash their hands after any contact with residents, before and after entering rooms, before providing any care, when care was completed, before they start medication pass on an individual, and before and after donning gloves. The IP said, the risk of leaving one resident's room and then pushing the laundry cart down the hall uncovered to another resident's room was aerosol contamination and transfering from one resident to another. The IP stated, staff should not go in and out of rooms without washing or sanitizing their hands. The IP stated, there was a risk of contaminating one resident to another if not washing or not sanitizing hands before entering residents rooms. The IP stated, contaminated laundry should be bagged in the room, the bag put in the yellow barrel, transported to the laundry chute, and put down the chute in the bags. The IP stated, clean linens should be put in the large cart separated and covered. The IP stated, the dirty laundry that goes down the laundry chute should be contained for infection control. The IP stated, laundry should never be put down the laundry chute without being in a bag. The IP stated, staff should utilize hand hygiene after exiting a resident's room and when a staff member touches the floor because there was a risk of infection control. The IP stated, when an item goes into a residents room like a box of gloves or a package of wipes they would become dirty when it touches the surface and staff should get their gloves in the resident's room or bathrooms. The IP said, staff should never take in a box of gloves or package of wipes into other rooms due to infection control contamination. The IP stated, staff should perform hand hygiene before touching clean linen and should never set down contaminated items on clean linen.

Based on interview and review of facility employee training logs and transcripts, the facility failed to ensure Certified Nursing Assistant (CNA) #12 received required Dementia training from January 2023 through January 2024. This affected one of three employee files reviewed during the survey. Findings include: Review of CNA #12's employee training files revealed CNA #12 had a dire date of 12/09/2022 and she did not receive Dementia training for the time period January 2023 to January 2024. In an interview on 03/22/2024 at 04:19 PM with the Staff Development Coordinator (SDC) #5, she was asked about CNA #12's Dementia training. SCD #5 said, she was unable to locate CNA #12's Dementia training and CNA #12 had some technical difficulties and had not completed the required training. When asked should CNA #12 have had Dementia training, SDC #5 said, yes, and until she completed the required training, CNA #12 had been taken off the schedule.

Based on observations, interviews, medical record review, and review of a facility policy titled, Medication Storage, the facility failed to ensure Vitamin B12 tablets were disposed of by the expiration date and not left on the medication cart and administered to Resident Identifier (RI) #3 by Medication Technician (MT) #6. This was observed on 01/21/2024 during medication administration observations and had the potential to affect RI #3 one of three residents observed for medication administration. Findings include: A facility policy titled Medication Storage with a reviewed date of 04/2020 documented: . Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedures . 11. Outdated, contaminated, or deteriorated medications . are removed from stock, disposed of according to procedures for medication disposal, . RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #3's 2024 Physician Orders documented an order dated 12/29/2020 for Cyanocobalamin (Vitamin B12) one tablet to be given daily. An observation was made on 03/21/2024 at 08:00 AM during medication administration with MT #6. MT #6 prepared Vitamin B12 medication for RI #3 from a bottle of Vitamin B12 tablets with an open date of 12/2017. On 03/21/2024 at 08:36 AM MT #6 administered the medication to RI #3. On 03/21/2024 at 09:06 AM the Vitamin B12 bottle with the open date of 12/2017 was observed with MT #6 to have an expiration date of 02/2024. MT stated, the medication technicians, nurses, and nurse managers were responsible for checking the medications expiration date on the medication cart daily. MT stated, expired medication had the risk of the not being effective. MT #6 stated, she did not pay attention to the date on the medication when she administered medications to RI #3. An interview with the Director of Nursing (DON) was conducted on 03/22/2024 at 12:07 PM. The DON stated, when staff administer medications, they should look for the right person, medication, the route, and the expiration date. The DON stated, there was a risk of the effectiveness of the medication when given past the expiration date. The DON stated, expired medications should have never been on the medication cart.

Based on interviews, resident record review, and review of a facility policy titled Incidents and Accidents the facility failed to ensure Resident Indentifer (RI) #81 and RI #26 was not left alone after being dropped off unaccompanied at a local health clinic on 01/25/2024. This affected 2 of 4 residents sampled for accident concerns. Findings include: On 01/25/2024 at 12:42 PM, the State Survey Agency received an initial report from the facility via the Online Incident Reporting System regarding an allegation of possible abuse-neglect that occurred on 01/25/2024 at approximately 10:30 AM. According to this initial report, RI #81 was transported to a local hospital medical clinic on 01/25/2024 at 7:15 AM unattended. The driver escorted RI #81 into the clinic and returned to the facility at approximately 7:35 AM to pick up RI #26 for an appointment at the same clinic. When the driver to with clinic he saw RI #81 standing outside the clinic in the rain. A facility policy titled Incidents and Accidents with an effective date of 11/10/2014 documented: . The resident/guest environment remains as free of accident hazards as is possible, . An incident is an occurrence that may not be consistent with the routine operation of the facility or the routine care of a particular resident/guest. RI #81 was admitted to the facility on [DATE]. RI #81's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/2023, documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. RI #26 was readmitted to the facility on [DATE]. RI #26's quarterly MDS assessment with an ARD of 10/26/2023 documented RI #26 had both long and short term memory problems and moderately impaired cognition. An interview was conducted with RI #81 on 03/18/2024 at 4:49 PM. RI #81 stated, she arrived at the clinic on 01/25/2024, and was the first one there. RI #81 said, the secretary at the clinic stated they did not open until 8:00 AM, so RI #81 explored the building upstairs before going outside and then waited outside for the driver. RI #81 continued, when he arrived with another resident, they went inside for the appointment. RI #81 added, once inside, an employee of the facility joined the appointment, and they were transported back to the facility afterwards. On 03/19/2024 at 2:46 PM, an interview was conducted with the Transport Driver. He said, on 01/25/2024, he accompanied RI #81 to the clinic for an appointment. He opened the door for RI #81 and RI #81 proceeded to the front desk where to sign in. After that, the driver said, he returned to the facility and picked up RI #26 for an appointment at the same clinic. Upon his return, he noticed RI #81 was walking outside in the misting rain. He observed RI #81's clothes were damp from standing in the rain. The driver then escorted both residents into the clinic for their appointments. On 03/20/2024 at 11:25 AM, an interview was conducted with Certified Nursing Assistant (CNA) #14. CNA #14 reported that she had arrived at work on 01/25/2024 around 8:00 AM and she was informed there was no staff present for RI #81 and RI #26 at their scheduled appointment. CNA #14 said, she then proceeded to the clinic and stayed with the residents until the driver arrived to transport both residents back to the facility, and she followed in her own vehicle. CNA #14 said, that her duty during resident appointments was to ensure their safety and prevent them from wandering off. On 03/20/2024 at 12:13 PM CNA #9 was asked about residents going out for appointments. CNA #9 said, she arranges staff schedules to accompany residents to medical appointments. She recalled an incident on 01/25/2024, when a CNA was supposed to accompany RI #81 and RI #26 to their appointment but called off. CNA #9 discovered that the residents had gone to the appointment unaccompanied when she arrived at around 8:00 AM. CNA #9 said, she then assigned another staff member to go with the residents. When questioned about why the residents were sent without a staff member, she attributed it to bad weather causing and staff calling out. On 3/20/2024 at 12:43 PM, an interview was conducted with the charge nurse, a Registered Nurse (RN) #15. During the interview, RN #15 said, on 01/25/2024, when he arrived at work, the transportation driver was present to pick up RI #81 and RI #26. According to him, the driver initially left with RI #81 and later returned for RI #26. He stated, no employee accompanied RI #81 when they left, and there was no employee following behind the transport van. The RN supervisor said, it was the facility's policy to have staff accompany residents to their appointments. RN #15 said, he assumed he CNA was to accompany residents at the appointment and he did not know she had called out. On 03/20/2024 at 2:57 PM an interview was conducted with the Administrator. She said, sending staff with residents to appointments had always been a practice to ensure continuity of care. She said the facility had no written policy regarding this but sending staff with residents to appointments had been consistently implemented by the facility. The administrator explained that the reason RI #81 and RI #26 were sent without a staff member on 01/25/2024 was due to the confusion with the call offs. When asked how the process has changed since this incident, she said, it was the same but they were more cautious. This deficiency was cited as a result of complaint/report number AL00046869. ************************* The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: - On 01/25/2024, the facility became aware of a resident being left at an appointment by there selves at a local hospital clinic. The resident did walk out of the lobby and outside in the misting rain. The resident stood outside until the driver returned with a second resident. Both residents were then walked into the clinic - A report was made to the Alabama Department of Public Health on 01/25/2024. - On 01/25/2024 an In-service began with License Nurses, and the Lead CNA who sets up staff to go on appointments with instructions for any time a resident leaves the facility for an appointment staff is always to accompany the resident and residents should never go to an appointment unaccompanied by a staff member. Completed 01/25/2024. - Monitoring began on 01/25/2024 at stand down regarding resident appointments and staff attending. Monitoring continued for four weeks with no issues. The facility continues to monitor resident appointments during AM and PM meetings; Monday - Friday. - Compliance has been met with no further concerns identified. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, and in-service/education records, the survey team verified the facility implemented corrective actions including monitoring that began 01/25/2024, thus F689 was cited at past non-compliance.

Based on interviews, resident record review, review of an Employee file, and review of a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure an allegation of exploitation was reported to the State Agency after the Administrator/Abuse Coordinator was made aware on 10/18/2023 of Licensed Practical Nurse (LPN) #13 taking money from Resident Identifier (RI) #27 on multiple occasions. This deficient practice affected RI #27, one of nineteen sampled residents and one of five residents investigated for abuse. Findings include: This tag was cited as a result of the investigation of complaint/report number AL00047241. The State Agency received the complaint on 03/15/2024 with the allegation that LPN #13 was terminated from the facility in the fall of 2023 because LPN #13 borrowed $500.00 from RI #27. Review of a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of 02/08/2018 revealed: . E. Exploitation is taking advantage of a resident/guest for personal gain through use of manipulation, intimidation, threats, or coercion. An example is monetary assistance provided to staff after informing resident/guest that they are in a financial crisis, gifts to staff by resident/guest(s) based on staff persuasion. VI. a) The facility will report all instances of alleged or suspected abuse, including . exploitation and misappropriation of resident/guest property in the following manner: b) Investigation and Reporting Steps . The Administrator/Designee will report to the State Agency . per regulations. Review of LPN #13's employee file revealed a facility form titled CONFERENCE REPORT dated 10/18/2023. The report documented a violation as follows: . Type A Violation #20: Engaging in fraudulent Activity by violating our Corporate Compliance Policy and Procedure: (LPN #13) . on multiple occasions took money from the resident . This activity was overheard by another Resident, the roommate and reported the activity to the Administrator. When the Resident . was questioned (he/she) acknowledged (he/she) would give her the money that was in (his/her) billfold when (he/she) was asked. (He/She) stated this occurred on multiple occasions. HR was notified and informed of the situation, they were in agreement with termination. RI #27 was admitted to the facility on [DATE] and a readmitted [DATE]. On 03/22/2024 at 12:50 PM an interview was conducted with the Abuse Coordinator (AC)/Administrator (ADM). The ADM said, she had talked to RI #27 and was told that LPN #13 would ask for money and RI #27 would give her money. The ADM stated, the incident had not been reported to the State Agency but LPN #13 was terminated. The ADM stated, the situation should have been reported to the State Agency because it was regulatory and there was a concern of it not being reported. On 03/22/2024 at 04:00 PM an interview was conducted with RI #27. RI #27 stated, he/she would give money to LPN #13 when she needed it. RI #27 stated, he/she would only give LPN #13 a little money at a time, like $30.00, and LPN #13 had a bad home life and needed money to come to work.

Based on record review and interview the facility failed to ensure Resident Identifier (RI) # 47's quarterly Minimum Data Set with and Assessment Reference Date (ARD) of 1/22/21 and 4/23/21 were coded to reflect RI # 47 receiving hospice and oxygen. This affected 1of 1 resident sampled for hospice and 1 of 2 residents sampled for oxygen. Findings Include: A review of RAI Version 3.0 Manual documented .O0100K, Hospice care Code residents identified as being in a hospice program .O0100C, Oxygen therapy code continuous .oxygen administered via mask, cannula .delivered to a resident . RI # 47 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #47's June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2L(liters)/Min Per Nasal Cannula Continuously .11/14/19 .Admit to .Hospice . A review of RI # 47's MDS with an ARD of 1/22/21 did not document RI # 47 receiving oxygen or hospice A review of RI # 47's MDS with an ARD of 4/23/21 did not document RI # 47 receiving oxygen or hospice. An interview was conducted on 6/10/21 at 2:15 PM with Employee Identifier (EI) # 1, Registered Nurse. EI #1 was asked was RI # 47 on continuous oxygen when you completed the quarterly MDS for 1/22/21 and 4/23/21. EI #1 replied, yes according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 replied, no not on either 1/22 or 4/23. EI #1 was asked, was the oxygen checked for 1/22/21 and 4/23/21. EI #1 replied, it was not checked for 1/22/21 or 4/23/21 Quarterly MDS. EI #1 was asked was RI #47 currently on oxygen. EI #1 replied, yes at two liters continuous since 2/10/20. EI #1 was asked should it be checked to show RI #47 was receiving oxygen continuously. EI #1 replied, yes. EI #1 was asked why it wasn't. EI #1 replied, she misread the order, it was a coding error. EI #1 was asked what was the benefit of an accurate MDS. EI #1 replied, it benefited the facility and patient to ensure appropriate care was provided.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #81 and/or RI #81's representative (sponsor) was provided written notice which specified the duration of the bed hold, reserve bed payment, the facility's policy regarding bed hold and the conditions upon which RI #81 would be able to return to the facility, when RI #1 was discharged from the facility to the hospital on [DATE], 4/20/2018, 1/9/2019 and 1/30/2019. This deficient practice affected RI #81, one of one sampled resident whose closed record was reviewed for discharge to the hospital. Findings include: RI #81 was readmitted to the facility on [DATE]. The facility's Detail Admission / Discharge Report dated 2/27/2019 indicated the following: RI #81 was discharged to the hospital on [DATE] and returned to the facility on [DATE]; RI #81 was discharged to the hospital on [DATE] and returned to the facility on [DATE]; RI #81 was discharged to the hospital on [DATE] and returned to the facility on [DATE]; and RI #81 was discharged to the hospital on [DATE]. RI #81's Quarterly and Discharge Minimum Data Set with an assessment reference date of 1/30/2019 indicated on 1/30/2019, RI #81 was discharged to an acute hospital, with return not anticipated. On 2/28/2019 at 8:55 AM, Employee Identifier (EI) #1, the Administrator was asked if the facility sent the bed hold notice to RI #81 and/or the resident's representative when RI #81 was transferred (discharged ) to the hospital on [DATE]. EI #1 said no, they did not. During a follow-up interview on 3/1/2019 at 3:30 PM, EI #1, the Administrator, stated the facility only issued the notice of bed hold policy upon admission. EI #1 further stated that RI #81's representative was informed of the bed hold policy once, during the admission process, but the notice was not issued at any other time.

Based on review of Resident Identifier (RI) #81's medical record, RI #81's hospital record and interviews, the facility failed to allow RI #81 to return to the facility following transfer (discharge) to the hospital. Despite reports from the acute care facility indicating that RI #81's behaviors were now stable and the resident was safe to return to a nursing home setting, the facility denied the request to allow RI #81 to return to the facility. This deficient practice affected RI #81, one of one sampled residents whose closed record was reviewed for discharge to the hospital. Findings include: RI #81 was readmitted to the facility on [DATE]. RI #81 has a medical history to include [DIAGNOSES REDACTED]. RI #81's Quarterly and Discharge Minimum Data Set (MDS) with an assessment reference date of 1/30/2019, indicated RI #81 was moderately impaired in cognitive skills for daily decision making, with long and short term memory problems. RI #81 displayed behaviors of [MEDICAL CONDITION] and had verbal behavior symptoms directed towards others and other behavioral symptoms not directed towards others for one to three days during the assessment period. Also, RI #81 rejected care one to three days during the assessment period. According to this MDS, RI #81 was discharged from the facility to an acute hospital on [DATE] with return not anticipated. In an interview on 2/27/2019 at 4:57 PM, Employee Identifier (EI) #3, the facility's Social Worker, was asked why the hospital was planning to send RI #81 to a different facility. EI #3 said it was because the Administrator (EI #1) felt like the facility could no longer meet RI #81's needs when they sent the resident out to the hospital on [DATE]. During an interview with RI #81's sponsor on 3/1/2019 at 2:35 PM, she stated she had been made aware by the hospital that RI #81 would not be allowed to return to Civic Center. The local hospital's Case Worker, also RI #81's discharge planner, was interviewed on 3/1/2019 at 12:32 PM. When asked if Civic Center had informed her they would not take RI #81 back at their facility, the Case Worker said, yes, the Administrator (EI #1) had told her the facility would absolutely not be taking RI #81 back. When asked when she was provided this information, the Case Worker said one day the prior week (week of 2/25/2019). The Case Worker explained that RI #81 was safe, stable and ready to be transferred back into a nursing home setting. When asked if RI #81 had exhibited any signs of combative behaviors, the Case Worker said staff had reported there were none. When asked how long RI #81 had been ready for discharge from the hospital, the Case Worker said two or more weeks. The Case Worker indicated RI #81's medications had been adjusted while the resident was in the hospital, and she felt RI #81 was stable enough to go back into the nursing home. Contained within RI #81's local hospital medical record was a document labeled Discharge Plan Update dated 2/14/2019, which documented . Patient Name: (RI #81) . Discharge plan update . Civic Center reports that pt. (patient) cannot return . Contained within RI #81's local hospital medical record was a document labeled Progress Note dated 2/15/2019, which documented . Patient (RI #81) remains very intrusive, requires frequent redirection, however, has been calm and cooperative. No aggression or combative behavior noted . Patient is taking medications as prescribed . On 2/28/2019 at 8:55 AM, an interview was conducted with EI #1, the Administrator. When asked if she told the hospital the facility would not accept RI #81 back, EI #1 said yes. EI #1 said she told the Case Worker at the hospital they would not be taking RI #81 back because they could not force the resident to take his/her medications; RI #81 had refused to allow his/her roommate to come into their room; and RI #81 was violent with staff. EI #1 said she did not feel she could take RI #81 back due to the safety of the other residents and staff; however, EI #1 confirmed the hospital Case Worker had reported to her that RI #81 was calm and compliant.

Based on review of Resident Identifier (RI) #81's medical record, the facility's policy titled VI. THERAPEUTIC LEAVE, TRANSFER, AND DISCHARGE and interviews, the facility failed to issue a notice of discharge to RI #81 and/or RI #81's representative (sponsor) when RI #81 was discharged to a local hospital on [DATE]. According to staff interview, the facility did not plan on accepting RI #81 back into their facility when the resident was discharged to the local hospital on [DATE]. This deficient practice affected RI #81, one of one sampled residents reviewed for a facility initiated discharge. Findings include: The facility's undated policy titled VI. THERAPEUTIC LEAVE, TRANSFER, AND DISCHARGE documented .Transfer/Discharge . The Facility will provide notice to you and your Responsible Party and, if known, a designated family member of your transfer or discharge and the reason for it at least thirty (30) days before you are transferred or discharged . Where your health and safety or the health and safety of other individuals in the Facility may be endangered, however, or where other good cause or legal reasons exist, notice may be given as soon as practicable before your transfer or discharge . RI #81 was readmitted to the facility on [DATE]. RI #81 has a medical history to include [DIAGNOSES REDACTED]. RI #81's Quarterly and Discharge Minimum Data Set with an assessment reference date of 1/30/2019, indicated RI #81 was discharged from the facility to an acute hospital on [DATE] with return not anticipated. During an interview on 2/27/2019 at 3:54 PM, RI #81's sponsor was asked if anyone at Civic Center had contacted her stating RI #81 had been discharged from their facility. RI #81's sponsor said no. In an interview on 2/27/2019 at 4:57 PM, Employee Identifier (EI) #3, the facility's Social Worker, was asked why the hospital was planning to send RI #81 to a different facility. EI #3 said it was because the Administrator (EI #1) felt like the facility could no longer meet RI #81's needs when they sent the resident out to the hospital on [DATE]. On 2/28/2019 at 8:55 AM, an interview was conducted with EI #1, the Administrator. When asked if the facility had issued a notice of discharge to RI #81 and/or RI #81's sponsor, EI #1 said they had not.

Based on observation, interview and review of the facility's policy titled, Sanitation Principles, the facility failed to ensure the kitchen floor, appliances and equipment were maintained in a manner to promote cleanliness and sanitation. This had the potential to affect all residents receiving meals from dietary. Findings Include: The facility's Policy and Procedure titled, Sanitation Principles, with an effective Date: February 1, 2002, addressed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Food service areas should be maintained in a clean and sanitary manner. PR(NAME)ESS: a. Kitchens and dining areas should be kept clean, . b. equipment should be kept clean, . The following observations were made in the kitchen on 2 of 3 days of the survey: 2/7/18 11:14 a.m., grease had accumulated on the floor around the deep fryer and on the backside of stove. A piece of okra was observed on back of stove. Grease had accumulated on the black gas pipes around the deep fryer. At 11:18 a.m., a food tray cart was observed dirty with an accumulation of a dark substance. Dietary staff were in the process of loading food trays on the rack. At 11:24 a.m., when the Dietary Manager, Employee Identifier (EI) #3 was asked how often the racks were cleaned, she replied, they were wiped down every evening and pressure washed weekly. 2/8/18 at 7:30 a.m., a food tray cart was observed with an accumulation of food / liquid substance. When brought to the attention of the EI #3, she removed the cart from the service line and gave it to dietary staff to wipe down. 7:34 a.m., the grease accumulation remained on the floor by the deep fryer and gas lines. When brought to the attention of EI #3, she reported that Maintenance cleans it but they have to let him know. on 2/8/18 at 8:05 a.m., The Maintenance Director (EI) #4 was interviewed. When asked who was responsible for ensuring kitchen floors and equipment were cleaned, he reported dietary staff is responsible for ensuring everything is cleaned.

Based on observation, interview and review of facility policy titled, Sanitation Principles, the facility failed to ensure the dumpster was maintained in order to prevent leakage and potential attraction of pest. This had the potential to affect all residents residing in the facility. Findings Include: The facility's Policy and Procedure titled, Sanitation Principles, with an effective Date: February 1, 2002, addressed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PR(NAME)ESS: d. Refuse containers and dumpsters outside the nursing facility should have tight fitting lids and should be kept covered when not actually being loaded. The areas around the the dumpster should be kept free of debris. On 2/7/18 10:49 a.m., during the inspection of the dumpster area with the Dietary Manager (DM), Employee Identifier (EI) #3, an observation was made of water standing in the bottom of the dumpster. Holes were observed in the dumpster lid which had allowed rain to enter and settle on the bottom. On 2/8/18 at 3:49 p.m., the Maintenance Director, EI #4, was interviewed and informed of the observations. When informed of the holes in the dumpster lid, EI #4 reported he and the facility had been in communication with the dumpster provider the last six months regarding replacement. EI #4 could not provide any documentation of communication with the dumpster provider.

Based on interviews, record reviews and facility care plan policy, the facility failed to ensure residents/ representatives were informed of care plan meetings and allowed the opportunity to attend the meetings. Residents reported not being notified of care plan meetings or having any knowledge of care plan meetings. This affected Resident Identifiers (RI) # 54, 9, 76 and 5, four of eighteen sampled residents reviewed for care plan meeting attendance. Findings Include: The facility's Policy and Procedure for Care Plans, effective date: April 29, 2015 addressed the following: PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the guest. PR(NAME)ESS: . II. Preparation for Care Plan Committee Meetings . c) The Social Service, or other designee, should inform the guest and families of the scheduled meeting . III. Conducting the Interdisciplinary Care Plan Meeting a) The team, including the guest when possible, should present findings from assessments, using information from the RAI (Resident Assessment Instrument), and discuss suggested new goals or approaches, as appropriate. . c) When the guest is unable to attend, but able to comprehend the plan of care, a review of the plan should be conducted by the care plan designee. The guest should sign the care plan acknowledging their involvement. 1) RI #54 was admitted the facility on 05/03/17. The BIMS (Brief Interview of Mental Status) on the 01/11/18 Minimum Data Set (MDS) Assessment identified the resident with a BIMS score of 10/15, moderate cognitive impairment. On 02/07/18 at 1:30 p.m., RI #54 was interviewed about care plan meetings. RI #54 was asked if he/she attended care plan meetings. RI #54 had no knowledge of care plan meetings and did not know what they were. Review of the Medical Record revealed no evidence of RI #54 attending care plan meetings. On 02/07/18 at 3:42 p.m., Employee Identifier (EI) #2, Social Service staff was interviewed. EI #2 was interviewed regarding care plan meetings and notification to residents and representatives. EI #2 reported there was no formal care plan meeting unless there were changes in a resident's condition. When evidence of notification and attendance was requested by surveyor, none was provided. 2) RI #9 was readmitted to the facility on [DATE]. The BIMS on the 11/8/17 MDS identified the resident with a BIMS score of 15/15, indicating no cognitive impairment. On 02/06/18 at 2:49 p.m., RI #9 was asked about attending care plan meetings. The resident reported he/she did not attend meetings and he/she was not informed of care plan meetings. On 020/7/18 at 3:10 p.m., EI #2 was interviewed and asked about notifying residents of care plan meetings. EI #2 reported she did not notify the resident of care plan meetings. 3) RI #76 was readmitted to the facility on [DATE]. The BIMS on the 01/24/18 MDS Assessment identified the resident with a BIMS score of 10/15, moderate cognitive impairment. On 02/08/18 at 10:53 a.m., RI #76 was asked about attending care plan meetings. The resident had no knowledge of care plan meetings. On 02/08/18 at 4:00 p.m., the facility was asked to provide proof of RI #76 attending care plan meetings. None was provided to the surveyor. 4) RI #5 was readmitted to the facility on [DATE]. The BIMS on the 11/7/17 MDS identified RI#5 with a BIMS score of 15/15. Indicating no cognitive impairment. On 02/06/18 at 3:04 p.m., RI #5 was interviewed and asked about attending care plan meetings. The resident reported he/she had never attended a care plan meeting, nor was he/she ever told about it. On 02/08/18 at 4:00 p.m., the facility was asked to provide proof RI #5 attended care plan meetings. No evidence was provided, when asked by the surveyor.

Based on interview, record review and review of a facility policy titled CONTROLLED DRUG DESTRUCTION, the facility failed to ensure licensed staff dated one of two Record of Medication Destruction sheets for the month of February 2017. This was found in one of thirteen months of narcotic destruction sheets reviewed. Finding Included: A facility policy titled, CONTROLLED DRUG DESTRUCTION, dated 03/11 documented: . Procedures . 6. The registered nurse and pharmacist should ensure that the following information on the 'Record of Medication Destruction' is correct in the appropriate space on the form: A. Date of destruction . On 02/8/18 at 7:45 a.m., the surveyor reviewed the narcotic Record of Medication Destruction sheets, for the month of February 2017. The surveyor observed one of two medication destruction sheets which did not contain a date by one of the three signatures on the sheet. The medication destruction sheet indicated that [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME]), Klonopin ([MEDICATION NAME]) had been destroyed by the pharmacist and facility staff. On 02/8/18 at 4:00 p.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1, where was her signature on the drug destruction records. EI #1 said she had not signed the drug destruction record sheet. The surveyor gave EI #1 the drug destruction sheet for review. EI #1 viewed the Controlled sheet dated 2/14/17. The surveyor asked EI #1 what was missing. EI #1 said the date is not on the sheet when the medication was destroyed.

Based on interview, record review and review of a facility policy titled, NON-CONTROLLED DRUG DESTRUCTION, the facility failed to ensure the NON-CONTROLLED MEDICATION DESTRUCTION record were maintained in the facility for record keeping purposes. Further, the facility failed to ensure licensed staff dated the Record of Medication Destruction sheets. This included two of four sheets for 8/18/17, and two of four sheets for 12/13/17. This was found in one of thirteen months of NON-CONTROLLED DESTRUCTION RECORD sheets reviewed. Finding Included: A facility policy titled CONTROLLED DRUG DESTRUCTION, dated 03/11 documented: . Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pick-up, ensures that the following is entered on the 'Record of Medication Destruction' form . A. Date of destruction . 4. These records should be maintained in the facility for record keeping purposes . On 02/8/18 at 8:35 a.m., the surveyor reviewed the NON-Controlled Record of Medication Destruction sheets for the months of August 2017 and December 2017. August 18, 2017, four of seven destruction sheets were not dated and one of seven destruction sheets was missing. December 13, 2017, two of four destruction sheets were not dated. On 02/08/18 at 4:20 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director Of Nursing (DON). The surveyor asked EI #1 if page one of three pages or two of three pages were missing from the non-controlled medication record. EI #1 said page one of three pages is missing. The surveyor asked EI #1 if the nurse dated the back pages of two of three pages on the the non- controlled medication destruction log. EI #1 said no.

Based on record review, interview, and a review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure dementia care was included in the required continued education training for Certified Nursing Assistants (CNAs) for the last twelve months. This affected two of seven randomly reviewed records for CNA training. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation , with an effective date of February 8, 2018, page 7, revealed; . b) . Facility will educate staff using Hand in Hand video on dementia management, effective communication, understanding resident/guest(s) behavioral symptoms to include: wandering elopement type behaviors, resistance to care, outbursts, yelling out and difficulty adjusting to new routines and staff, and resident/guest abuse prevention. This training will be conducted upon hire and at least annually. On 2/8/18 at 8:00 a.m., seven randomly chosen facility employee records were reviewed for dementia training. Two of the seven employee records did not include dementia training recorded for the past year. An interview was conducted on 2/8/18 at 9:30 a.m. with Employee Identifier (EI) #1, Registered Nurse/Director of Nursing. EI #1 was asked why the facility failed to document or conduct dementia training for two of the seven randomly selected employees. EI #1 stated it was due to a lack of staff development. EI #1 was asked who was responsible for staff development or training at the facility. EI #1 replied, it was an open position at present but ultimately it was the responsibility of the Director of Nursing or the Administrator. EI #1 was asked what was the potential for harm if CNAs did not receive dementia training. EI #1 stated the staff would not know how to care for residents with dementia. FACILITY Sufficient and Competent Nurse Staffing 02/08/18 06:12 PM

Based on interviews, record review, review of a facility policy titled Elopements and Wandering Residents, Resident Identifier (RI) #1's hospital records and review of the facility's investigative file, the facility failed to ensure RI #1, a resident with severely impaired cognition and a history of exit seeking behaviors, did not exit the facility without staff knowledge. On 07/16/17, RI #1 was observed wandering in and out of residents room and asking if he/she could leave the facility. RI #1 was later observed on the facility's video footage going into the main dining room. Employee Identifier (EI) #13, a Certified Nursing Assistant (CNA), assigned to care for RI #1 stated she observed RI#1 being agitated prior to the resident exiting the facility. EI #13 stated she left the resident in the dining room with another resident (RI#13), who was also displaying signs and symptoms of agitation. EI #13 stated there was no staff members present in the dining room when she left RI #1 to provide care to other residents assigned to her. Interviews with dietary staff revealed there was a door leading from the dining room into the kitchen that did not lock automatically when it was shut, but it would lock when a person physically locked the door. Dietary staff stated after entering the kitchen there is an exit door, that leads from the kitchen to outside, where RI #1 was found. Dietary staff admitted the exit door had been left opened when a Dietary staff member went outside to put trash into the dumpster. EI #4, a Dietary Aide/Cook observed RI #1 leaning against a wall outside. RI #1 had on one shoe and one bloody sock. An interview with the Dietary Manager revealed when RI #1 entered the kitchen the resident could have possibly been burned, cut, scolded or slipped on the floor. RI #1 was brought into the facility and assessed by EI #12, a Licensed Practical Nurse (LPN). RI #1 was noted to have a protrusion from the inside of the left ankle which appeared to be broken. RI #1 was transferred to a local hospital and X-rays revealed RI #1 had left tibia and fibula fractures which required surgical intervention. On 09/14/17, at 9:56 a.m., the Administrator, the Regional Administrator and the Regional Nurse Consultant were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 323. The immediate jeopardy began on 07/16/17. Beginning on 07/16/17 until 07/18/17, the facility implemented corrective actions to prevent recurrence of the identified deficient practices; thus immediate jeopardy past non-compliance was cited. This deficient practice placed RI #1, one of three residents sampled for wandering/elopement, in immediate jeopardy of serious injury, harm or death. Findings Include: Review of a facility policy titled Elopements and Wandering Residents with an effective date of May 30, 2014, documented: PURPOSE: To identify those residents who wander so that appropriate interventions can be put in place in an effort to provide adequate supervision and safety. STANDARD: . The facility should be equipped with door locks/alarms to help avoid elopements . RI #1 was readmitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 had a medical history to include: Peripheral Vascular Disease, Mild Cognitive Impairment, Gangrene, COPD (Chronic Obstructive Pulmonary Disease), Primary Open-Angle Glaucoma, Dementia, Long-term use of Anticoagulants and Acquired Absence of Right Great Toe. RI #1's Admission Minimum Data Set with an Assessment Reference Date of 06/17/17, assessed RI #1 to score a 3 on the Brief Interview for Mental Status indicating severely impaired cognition. RI #1 was also assessed as having wandering behaviors which had occurred four to six days during this assessment period. RI #1 was assessed as needing supervision with walking in the room and in the corridor and with locomotion on and off the unit. RI #1's Departmental Notes documented the following: . 6/13/2017 3:39 AM . RESIDENT UP WALKING MOST OF THE NIGHT. RESIDENT CONTINUES TO WALK TO THE DOOR TRYING TO LEAVE, WALKING IN AND OUT OTHER RESIDENTS ROOMS . 6/16/2017 10:34 PM . Resident has been trying to get out of doors stating (he/she) has to wait on (his/her) grandson. Resident redirected several times . 6/17/2017 8:34 AM . The resident is currently ambulating without the assistance of staff, (he/she) has made several attempts to try and exit the building . 6/21/2017 4:01 AM . The resident is currently walking throughout the facility, (he/she) is being closely monitored; due to (his/her) risk of elopement . 7/2/2017 10:18 PM . RESIDENT HAS BEEN CONFUSED ENTIRE SHIFT WORSENING AS THE NIGHT CAME ALONG. RESIDENT HAS BEEN WONDERING (WANDERING) IN AND OUT OF ROOMS, TRYING TO EXIT FACILITY THRU DOORS AND EVEN ATTEMPTED GOING THRU WINDOW THAT LEADS INTO DIETARY AREA/KITCHEN . 7/17/2017 1:15 AM . 7/16/2017 Resident alert and oriented to self only, baseline. CNA, myself and many other staff members have been redirecting resident all shift. (He/She) has been repeatedly wandering into other residents rooms throughout the shift . Redirection has been mostly unsuccessful as resident returns to behavior only minutes after redirection. I began to check on resident's location about every 20 to 30 minutes. During one of my checks I did not see resident. I checked (his/her) room and did not see (him/her) so I began to walk the building to see if (he/she) had gone into another resident's room. The last time I had seen resident was at smoke break in the courtyard area which was only about 15 to 20 minutes prior. CNA had reported seeing resident in the main dining room area after my own last sighting of (him/her). Only minutes afterwards a staff member from the kitchen reported seeing resident outside by the dumpster. CNA and I ran outside and found resident standing/ leaning on the wall near the dumpster on the outside of the main dining room. Resident had sustained an abrasion to (his/her) right forearm near the elbow and (his/her) left sock was moderately bloody. Approximately 7:10 pm resident was taken back inside via (by way of) wheelchair for further assessment and treatment. When the bloody sock was removed there was an abrasion to (his/her) great toe and a protrusion from the inside of resident's left ankle. The protrusion did not break through the skin and was possibly a break or fracture . At approximately 8:00 pm Resident was taken to (local hospital) via (name) Paramedic Services for further evaluation and treatment. Called (local hospital) at 11:00pm to get an update on resident's status. Reident (Resident) was admitted with a Dx (diagnosis)/Dislocation left tibia. RI #1's Diagnostic Radiology report from the local hospital, dated 07/16/17, revealed RI #1 sustained fractures of the left ankle. RI #1's History and Physicals from the local hospital dated 07/17/17, documented: . Impression and Plan . Reduced and splinted in ED (Emergency Department) . Plan for possible operative interventions in the AM . Addendum . Plan for external fixation today with delayed ORIF (Open Reduction Internal Fixation) . History of Present Illness (HPI) Chief Complaint: L (left) ankle fracture, AMS (Altered Mental Status) . Admission HPI . (RI #1) presented . today for left ankle fracture. According to the note patient left NG (Nursing) facility and found to be outside of facility . Contained within the facility's investigative file was EI #4's, the Dietary Aide/Cook, typed statement dated 07/17/17, which documented: On Sunday July 16, 2017 I was taking out the trash around back of the facility. I saw (RI #1) leaning up against the dumpster. (RI #1) was standing up on both feet. I asked (RI #1) what (he/she) was doing out here but I couldn't understand what (RI #1) was saying. (RI #1) had one shoe on and one shoe off . (RI #1) was leaning on the wall so I ran around to get help. (EI #12, the assigned LPN) and (EI #13, the assigned CNA) came out immediately . (EI #11, another CNA) came in while nursing checked (RI #1) and got a wheelchair. I don't know how (RI #1) got out . On 09/11/17 at 3:40 p.m., the surveyor conducted an interview with EI #4. EI #4 said when she first observed RI #1 on the outside of the facility on 07/16/17, RI #1 was leaning against the wall by the dumpster where the dietary staff took the trash out. EI #4 said RI #1 had one shoe on and one shoe off. EI #4 said she ran back into the side door, where dietary staff exit to take the trash out, to get help. When asked if that exit door was set up with the Wanderguard system, EI #5 replied no. EI #4 said she notified EI #12, the assigned LPN and EI #13, the assigned CNA and they both went outside. EI #4 also said EI #11 came out with a wheelchair. Contained within the facility's investigative file was EI #11's, a CNA, undated typed statement which documented: . I was assigned to (RI #1) on the 7-3 shift . (RI #1) was ok but still confused on the 7-3 shift. I couldn't get him settled. (RI #1) would focus on something then need to move. (RI #1) would just I need to go . After the shift change (RI #1) got more erratic and was all over the place. In and out of other residents room. We redirected (RI #1) constantly . I did come across (RI #1) during the 6:30 (6:30 p.m.) smoke break. I asked (RI #1) . to hang out with me and (RI #1) did in the courtyard. (RI #1) came and sat down a few minutes and smoked. (RI #1) still wouldn't be still. (RI #1) wouldn't be still even smoking. (RI #1) smoked about half (a cigarette) and then insisted about going back inside. Maybe 10-15 minutes outside. Around 7 (7:00 p.m.) when I came back around, (EI #13) was asking if I had seen (RI #1). I took the smoking box back behind nursing station. At this time the lady from the kitchen came and asked who was (RI #1's) CNA because (RI #1) was outside. By the time I got outside (EI #12) and (EI #13) was already outside. I ran back in and got the wheelchair and brought it out when we saw (RI #1's) foot. We put (RI #1) in the wheelchair and brought (RI #1) back in . On 09/11/17 at 6:11 p.m., the surveyor conducted an interview with EI #11, the CNA assigned to care for RI #1 during the 7-3 shift on 07/16/17. EI #11 said around lunch was when RI #1 started to get confused. EI #11 said she had other residents so she could not do one on one with RI #1. EI #11 said around 6:30 p.m., it was smoke break for the residents and she got RI #1 to sit down for a minute and smoke but RI #1 still would not be still. EI #11 said RI #1 was on the edge of his/her seat and kept saying, 'I got to go, I got to go.' EI #11 said after RI #1 finished smoking, RI #1 went back into the facility by him/herself. EI #11 said smoke break was over at 7:00 p.m. EI #11 said when she went back into the facility and was coming from the Station where she had put the cigarettes, one of the ladies from the dietary department was asking who RI #1's nurse was. EI #11 said the dietary staff member said RI #1 was outside by the dumpster. EI #11 said EI #13 had asked her when she (EI #11) got back to the floor had she seen RI #1. EI #11 said this was before the dietary staff member came to the hall. EI #11 said since she left the smoking area, she had not seen RI #1. When asked when was the next time she observed RI #1, EI #11 replied, RI #1 was near the dumpster leaning on the wall standing between EI #12 and EI #13. EI #11 said RI #1 had on one shoe and RI #1's pants were dusty on the front and it seemed as if RI #1 had fallen. EI #11 said she noticed blood on RI #1's left sock. EI #11 said she went to get a wheelchair and that was how RI #1 was brought back into the facility. EI #11 said when she first ran out to help, the alarm at the door used by the dietary staff to take trash out was sounding. Contained within the facility's investigative file was EI #12's, the assigned LPN's undated typed statement which documented: Dietary employee initially notified me that a resident was outside . She said that (RI #1) was by the dumpster . At that time I went right outside. Me and (EI #13, RI #1's assigned CNA) ran outside. At that time I witnessed (RI) leaning up against the wall of the building across from the dumpster. Seemed to be putting all of (his/her) weight on one leg. I couldn't tall (tell) initially that (RI #1's) leg could have been injured at the time due to (RI #1's) socks. Moderate amount of blood on (RI #1's) sock. Abrasion was noted on rightforarm (forearm) and on the other arm and the left calf. Right foot toe had skin tear like scraped on pavement. Determined that (RI #1) did not knee (need) to walk so (EI #11) who had come out when (went) and got a wheelchair. When we got (RI #1) back in I could tell that there was injury to left leg due to bulge at the ankle. It was loose when I was taking sock off. At that point something was going on so I called the on call nurse and notified DON (Director of Nursing) . I cannot say how (RI #1) got out. I did not witness (RI #1) getting out . I had been with (RI #1) off and on all during the shift . On 09/12/17 at 8:05 a.m., the surveyor conducted an interview with EI #12, the LPN assigned to care for RI #1. EI #12 said RI #1 had to be watched because RI #1 would wander in other residents rooms. EI #12 said that was an occasional thing for RI #1 but, on 07/16/17, it was worse than normal. The surveyor asked EI #12 when was he made aware RI #1 had exited the facility without staff knowledge. EI #12 said because of the way RI #1 was behaving that day he (EI #12) was checking on RI #1 every 30 minutes. EI #12 said when the time line of the incident was done. EI #12 said they figured it was 15-17 minutes that RI #1 was out of staff site. EI #12 said a woman from the kitchen approached him around 7:00 p.m. and told him she saw RI #1 outside. EI #12 said when he first observed RI #1, the resident was leaning up against the side of the building on the opposite side of the dumpster. EI #12 said RI #1 was not putting much weight on his/her left leg. EI #12 also said there was a little blood on RI #1's left sock and it looked like RI #1 had scraped one of his/her toes on the pavement. EI #12 said RI #1 was wearing one sock and the other foot did not have a sock on it. EI #12 said after RI #1 was transferred to the hospital, he called to ask for the admitting [DIAGNOSES REDACTED].#1 had a dislocated left tibia. When asked how he thought RI #1 exited the facility without staff knowledge, EI #12 replied he really did not know. Contained within the facility's investigative file was a statement from EI #14, a dietary aide, taken by EI #1, the Administrator which read: I was working that day when (EI #4) found (RI #1) outside. We were running behind so she (EI #4) was out taking her trash. I did not see (RI #1) come through the kitchen. I mean we have left that door open when we take the trash out but I don't know how (RI #1) would have gotten around there while (EI #4) was out there. On 09/12/17 at 11:54 a.m., a telephone interview was conducted with EI #14, the dietary aide. The surveyor asked EI #14 when did she find out RI #1 had exited the facility without staff knowledge. EI #14 said when EI #4 came back in the kitchen and said RI #1 was outside. When asked did the dietary department leave any of the doors open when they take the trash out, EI #14 replied, Yes. When asked which one, EI #14 said the back door. EI #14 said the back door lead to the outside to the narrow path that lead to the dumpster. EI #14 said you had to have a code to exit the back door. EI #14 said she did see EI #4 go out of the exit door on the evening of 07/16/17. The surveyor asked EI #14 did she see EI #4 prop or leave the door open. EI #14 said yes, it was left open. EI #14 said as soon as EI #4 went out of the exit door, it was not even three minutes when EI #4 came back and said RI #1 was outside. EI #14 said it was a little after 7:00 p.m. when the trash was taken out. The surveyor asked EI #14 if RI #1 had entered the kitchen that evening, how would he/she have entered. EI #14 said she did not know. EI #14 said the door leading from the dining room to the kitchen should be kept locked at all times. EI #14 said she was not sure if the door was locked on the evening of 07/16/17. Contained within the facility's investigative file was an undated typed statement from EI #13, the CNA assigned to care for RI #1, which read: (RI #1) was on my section that day. (RI #1) was all over the place . I kept redirecting (RI #1) to (his/her) room. After dinner time I took (RI #1) to the dining room and I sat (RI #1) at a table with (RI#13) as they both were a little agitated that day. I left out to go check on my other residents . (EI #12) came to me asking about (RI #1). I told him that (RI #1) was sitting in the dining room. When we checked, (RI #1) was not in the dining room. So we went to check around the facility. (EI #12) checked one side and I checked the other. By the time we made it back around to Station 2 (EI #4, a dietary aide/cook) was there saying that (RI #1) was at the dumpster out back. At that time, me and (EI #12) ran outside to (RI #1). (RI #1) was standing leaning up against the wall holding onto the drain pipe. (RI #1) kept saying that (he/she) was trying to get to the store. (EI #12) asked (RI #1) how (he/she) got out there and (RI #1) just babbled. At that time (EI #11) was there and (EI #12) told her to go inside and get a wheelchair . We assisted (RI #1) and put (RI #1) back in the wheelchair. We brought (RI #1) back into the facility. When we came in the door by dietary, the alarm sounded. The wanderguard alarm sounded when (RI#1) came back in .We took (RI #1) to is (his/her) room and they looked at (RI #1). (RI #1) was so agitated . The next thing I saw was (RI #1) going to the hospital. I have no knowledge of how (RI #1) got out. I don't know about the dietary door but I know that the door was open to (too) as they were taking the trash out. The alarm was sounding. I just wonder if (RI #1) went out that door. I just don't know. I was in the room with a resident so I can not say how (RI #1) got out. On 09/12/17 at 10:48 a.m., a telephone interview was conducted with EI #13. The surveyor asked EI #13 why had she sat RI #1 at the dining room table on that evening (07/16/17). EI #13 was asked were there any staff in the dining room when she took RI #1 to the dining room. EI #13 said no. EI #13 said this was around five something. EI #13 said it was after dinner time. The surveyor asked EI #13 when was she made aware RI #1 had exited the facility without staff knowledge. EI #13 said she really did not remember the exact time. EI #13 said EI #12 asked her had she seen RI #1. EI #13 said that was when the kitchen staff (EI #4) told her RI #1 was outside. EI #13 said she and EI #12 went outside and EI #12 asked someone to go and get a wheelchair. The surveyor asked EI #13 which door did RI #1 exit. EI #13 said the door by the kitchen. EI #1 said she heard the back door where trash is taken out, by dietary staff, sounding. EI #13 said the sound was a beeping sound which you will hear when you hold the door open for a minute. EI #13 said she knew that the door was open because it was sounding. EI #13 said this was the door that staff had to pass by to get RI #1. The surveyor asked EI #13 how RI #1 looked when she first saw the resident. EI #13 said RI #1 was saying he/she was trying to get to the store. EI #13 said RI #1's foot was messed up and it was bleeding. Contained within the facility's investigative file was an undated typed statement signed by EI #1, the Administrator which read: Upon Security Camera Observation Resident (RI #1) is last seen on camera going into Large dining room at 6:48PM At 7:06PM Dietary staff member informs nursing of the resident (RI #1) being out back of the facility. And Staff immediately rush outside to assess A 7:11PM resident is being assisted back into facility via (by way of) wheelchair. On 09/13/17 at 10:50 a.m., an interview is conducted with the Administrator, EI #1. The surveyor asked EI #1 when was he first made aware RI #1 had exited the facility and was found at the back of the facility. EI #1 said it was early on the morning of 07/17/17. EI #1 said he was told that RI #1 was found at the back of the facility and had exited the facility. EI #1 said at that time he started the investigation process to try to figure out what happened. EI #1 said to the best of his ability, he could not see RI #1 exiting the facility by way of the camera. EI #1 said when he reviewed the cameras he saw RI #1 going into the dining room area. EI #1 said he then saw RI #1 coming back into the facility 18 minutes later. When asked what was the facility's conclusion of how RI #1 exited the facility, EI #1 said he could not say. EI #1 said there was only one door in the facility that did not have a camera on it (the door in the kitchen where staff took trash out). The surveyor asked EI #1 what had been done after the incident to ensure the likelihood of an incident of this type happening again. EI #1 said the facility did door and window checks, implemented a camera and keypad on the dietary door to make sure all exit doors were secure, and in-serviced all staff on the elopement and door policies. EI #1 said the facility was still monitoring the exit doors to ensure they were locked, they had checked all Wanderguard's to make sure they were functioning and anything else they did was in the facility's investigative file. On 09/13/17 at 4:48 p.m., the surveyor conducted an interview with EI #17, the Dietary Manager. The surveyor asked EI #17 how should the doors leading from the dining room to the kitchen be kept. EI #17 replied, Closed at all times. EI #17 said when the doors are closed, the doors are locked. EI #17 said staff and residents cannot just walk in. EI #17 said prior to RI #1 exiting the facility without staff knowledge, the door to the kitchen from the dining room was always kept shut but did not automatically lock. EI #17 stated after the incident, the door lock was changed on that Monday (07/17/17) following the Sunday (07/16/17) elopement and now it automatically locked. The surveyor asked EI #17 what were some of the thing that could possible occur to negatively affect a resident entering the kitchen without staff knowledge. EI #17 said the resident could get burned, cut, scolded or slip on the floor. The surveyor asked EI #17 what was the door that exited to the outside of the kitchen used for. EI #17 said, Only to take out trash. The surveyor asked EI #17 should that door be propped open at any time. EI #17 replied, no. EI #17 said she was aware the door was being left open because it could not be reopened from the outside if it was closed. EI #17 said after the incident with RI #1, a keypad was put on the outside of the exit door, the doorknob on the door leading from the dining room to the kitchen was changed so that it automatically locks, dietary staff had been in-serviced on making sure all doors are secure at all times, and a sign had been posted on the inside door of the kitchen stating, Keep Door Closed At All Times. The surveyor asked EI #17 could the exit door leading from the kitchen to the outside be opened without using the keypad. EI #17 replied no, it will not open without using the keypad. ************************* Contained within the facility's investigative file was their Plan of Correction which documented: To address the issue of (RI #1) exiting the facility and the injury of unknown origin, the facility had implemented the following plan of correction as of July 17, 2017. 1. Upon notification of resident being noted outside of facility, nursing staff immediately assessed the resident for injury. The sponsor and MD (Medical Doctor) were notified and orders were given to send resident out for further evaluation at (local hospital). On 7/16/17. LPN checked doors and were found to be functioning appropriately. 2. On 7/17/17 all doors were checked by Maintenance Director and found to be functioning as appropriate. On 7/17/17 Windows were checked to ensure that they are secure opening 6-8 inches. On 7/17/17 all current residents who utilize a wanderguard bracelet were checked and all were found as appropriate and bracelet was functioning. On 7/18/17 (name of Contractors) were contacted to evaluate door alarm in dietary for hardwiring of wanderguard system and applying a surveillance camera monitoring the dietary exit door. (Alarm company) was contracted on 7/18/17 and a secondary keypad was ordered for the dietary door exit and self-locking door knob was added to dietary entrance door by facility maintenance staff. 3. All staff in-service was initiated on Elopement Protocol and Wanderguard system on 7/17/17. all absent staff inserviced by phone, will be re- inserviced when next reporting to work before resuming duties. Staff to have in-service prior to working next scheduled shift. Administrator in-serviced DON and RN (Registered Nurse) Nursing Management on timely reporting of all unusual occurrences immediately on 7/17/17. Nursing staff in-services initiated on monitoring and implementing appropriate intervention for residents who are displaying change in status. 4. Administrator and/or Maintenance Director will perform observations on all means of exit including doors and window checks for appropriate functioning 5 days a week for 2 weeks, then weekly for 2 weeks, followed by monthly for 2 months. Adverse findings will be immediately corrected. ************************* After review of the facility's investigation file, in-service/education records, staff interviews, and Quality Assurance plan, the facility implemented corrective actions from 07/16/17 to 07/18/17. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 329.

Based on observation, interview, and a facility cleaning policy, the facility failed to ensure the courtyard/smoking area was clean, uncluttered, and free of debris. This was observed on two of five days of the survey and had the potential to affect 16 of 16 residents who smoke in the facility. Findings Include: A review of an untitled and undated facility cleaning policy revealed the following documentation: . Clean the Patio Daily Police Throughout Day (after 9:30 smoke break and after 12:30 smoke break) . A list provided by the facility revealed there were 16 residents who smoked in the facility. On 9/10/17 at 5:30 PM, the Surveyor observed the courtyard/smoking area. Several empty yellow bins labeled soiled linen were observed in the courtyard. A small black crate was observed near the yellow bins. Also in the courtyard, there were cleaning items, including a mop and bucket. In addition, unknown debris was observed on the concrete floor in this area. On 9/12/17 at 9:00 AM, the Surveyor observed the courtyard/smoking area. Cigarette butts were observed on the concrete floor and trash was on the tables. Trash was observed on the concrete floor to include a plastic bag and paper. Several yellow bins, mops, a mop bucket, and a floor buffer were observed in the courtyard/smoking area. Also a broken chain link gate, closet doors, a broom, and metal debris were observed in the this area. On 9/12/17 at 9:30 AM, an interview was conducted with Employee Identifier (EI) #10, Housekeeping Supervisor. EI #10 was asked how often the courtyard was cleaned. EI #10 responded it was swept every morning and patrolled at midday to spot check. EI #10 was asked about the yellow bins that were observed on 9/10/17. EI #10 stated Certified Nursing Assistants (CNAs) put them there instead of behind the wall. EI #10 was asked who was responsible for cleaning the storage area where the mops/buckets and floor buffer were kept. EI #10 stated housekeeping and said they had gotten behind. EI #10 was asked if it needed to be cleaned. EI #10 responded yes and said it should be cleaned daily. EI #10 was asked what she observed behind the wall on the left side in the courtyard. EI #10 stated a floor buffer, mop equipment, a ladder, and an umbrella. EI #10 was asked what she observed on the right side of the courtyard. EI # 10 stated a closet door, a broom, metal debris, and a broken chain link gate. EI #10 was asked if it should be in the courtyard area. EI #10 stated no, it should not and further said it should be thrown away. This deficiency was cited as a result of the investigation of complaint/report number AL 329.

Based on interviews, record review and review of a facility policy titled Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to report an injury of unknown origin to the Division of Health Care Facilities (DHCF) within two hours. On 07/16/17, RI #1 sustained fractures to the left tibia and fibula which required surgery to repair. RI #1 was unable to explain how the injury occurred and this incident was not witnessed. This injury of unknown origin was not reported to DHCF until 07/17/17. This deficient practice affected RI #1, one of three residents sampled whose facility reports were reviewed. Finding Include: A facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of March 24, 2017, documented: . PURPOSE: . The facility's Policy requires that it report all instances of . suspicious injuries of unknown source that might indicate abuse, neglect, as required by state and federal law . C. Suspicious Injuries of Unknown Origin. An injury should be classified as an injury of unknown origin when both of the following conditions are met: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident/guest and (2) the injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example) the injury is located in an area not generally vulnerable to trauma) . Some examples of suspicious injuries of unknown origin may include, but are not limited to: . · unwitnessed fractures . VI. Investigation and Facility Response to Incidents or Accidents a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin . in the following manner: b) Investigations and Reporting Steps . The Administrator/Designee will report to state agency per regulations. All allegations of abuse or that result in serious bodily injury are to be reported immediately, but no later than 2 hours after the allegation is made . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment with an Assessment Reference Date of 06/17/17, assessed RI #1 to score a 3 on the Brief Interview for Mental Status indicating severely impaired cognition. RI #1 was assessed as needing supervision with walking in the room and in the corridor and with locomotion on and off the unit. RI #1's Departmental Notes documented the following: . 7/17/2017 1:15 AM . 7/16/2016 Resident alert and oriented to self only, . CNA (Certified Nursing Assistant) had reported seeing resident in the main dining room area after my own last sighting of (him/her). Only minutes afterwards a staff member from the kitchen (EI #4) reported seeing resident outside by the dumpster. CNA and I ran outside and found resident standing/leaning on the wall near the dumpster on the outside of the main dining room. Resident had sustained an abrasion to (his/her) right forearm near the elbow and (RI #1's) left sock was moderately bloody. Approximately 7:10 pm resident was taken back inside via (by way of) wheelchair for further assessment and treatment. When the bloody sock was removed there was an abrasion to (his/her) great toe and a protrusion from the inside of resident's left ankle. The protrusion did not break through the skin and was possibly a break or fracture . 7:17 pm I notified on call nurse and at 7:22 pm notified the DON (Director of Nursing) . At approximately 8:00 pm Resident was taken to (name of local hospital) via (name of ambulance service) for further evaluation and treatment. Called (name of local hospital) at 11:00 pm to get an update on resident's status. Reident (Resident) was admitted with a Dx (diagnosis)/Discoloration left tibia . A review of the facility's Confirmation of Receipt of Online Incident Report received by DHCF documented: . Date/Time Submitted: Monday, July 17, 2017 1:35 . PM . Incident Type: Select Category: Injuries of Unknown Source . Incident Detail . Descriptive of injury: (RI #1) was noted outside on the facility property standing against facility outside of the dining room. Resident was sent to local hospital for evaluation and is currently admitted with [DIAGNOSES REDACTED]. On 09/13/17 at 10:50 a.m., an interview was conducted with EI # 1, the Administrator. EI #1 was asked when he was made aware RI #1 had exited the facility and was found by staff. EI #1 responded early Monday morning, 07/17/17. EI #1 was asked if the incident was reported to the State. EI #1 responded yes. EI #1 was asked when was the incident reported. EI #1 stated, That Monday, I'm pretty sure. EI #1 was asked, when RI #1 exited the facility, did RI #1 receive any injuries. EI #1 responded RI #1 went to the hospital on Sunday and was [DIAGNOSES REDACTED]. EI #1 was asked if that was a serious bodily injury. EI #1 responded yes, it was an injury of unknown origin. EI #1 was asked what is the time frame for reporting a serious bodily injury. EI #1 responded two hours. EI #1 was asked was this incident reported within two hours of the time the facility found out about the fractured ankle. EI #1 responded, No, Ma'am. On 09/14/17 at 11:05 a.m., a telephone interview was conducted with EI #2, the Director of Nursing. EI #2 was asked was a fracture requiring surgical intervention serious bodily injury. EI #2 responded, Yes Ma'am. EI #2 was asked what is the time frame for reporting to the DHCF a serious bodily injury. EI #2 stated two hours. EI #2 was asked if the incident was reported within that time frame. EI #2 responded, No. This deficiency was cited as a result of the investigation of complaint/report number AL 329.

Based on observation, interviews, Potter and Perry's Fundamentals of Nursing, and record review, the facility failed to ensure Resident Identifier (RI) #12 received the scheduled doses of [MEDICATION NAME] 25 mg (milligrams) at 4:00 p.m. and 9:00 p.m., as ordered by the physician. This deficient practiced affected RI #12, one of four residents observed during the evening Medication Administration pass on 09/10/17. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of 2017, page 311, Chapter 23, Legal Implications in Nursing Process, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment with an Assessment Reference Date of 08/07/17, assessed RI #12 as scoring an 11 on the Brief Interview for Mental Status indicating moderately impaired cognition. RI #12 was identified as having received an Antipsychotic medication within the last seven days of this assessment period. RI #12's September 2017 Physician order [REDACTED]. A review of a Consolidated Delivery Sheet from the facility's Pharmacy, dated 09/09/17, revealed a quantity of 90 [MEDICATION NAME] 25 mg tablets had been delivered to the facility on [DATE] for RI #12. On 09/10/17 at 5:55 p.m., the surveyor observed Employee Identifier (EI) #19, a Licensed Practical Nurse (LPN) prepare medications for RI #12. EI #19 said RI #12's [MEDICATION NAME] was not available for administration. A review of RI #12's E-MAR (Electronic Medication Administration Record) revealed RI #12 did not receive the [MEDICATION NAME] 25 mg tablet at 4:00 p.m. or at 9:00 p.m. on 09/10/17. On 09/12/17 at 3:08 p.m., a telephone interview was conducted with EI #19. The surveyor asked EI #19 what was the facility's policy to ensure medications are available for administration. EI #19 said the policy was that the facility should not run out of medications. EI #19 said the Unit Manager or Director of Nursing (DON) should be notified when medications were not available. If RI #12's medications ([MEDICATION NAME]) were not administered, where the physician orders [REDACTED].#19 replied, No. On 09/13/17 at 9:35 p.m., an interview was conducted with EI #20, the Unit Manager of the unit RI #12 resided on. The surveyor asked EI #20 did RI #12 receive the medication [MEDICATION NAME]. EI #20 said, Yes she does. EI #20 was shown RI #12's E-MAR and asked what did the 'N on the MAR mean. EI #20 said, That it was not given. The surveyor asked EI #20 how many times on 09/10/17, did RI #12 not received the [MEDICATION NAME]. EI #20 replied, Twice. On 09/14/17 at 10:33 a.m., a follow-up interview was conducted with EI #20. EI #20 said when medications are delivered to the facility each nursing station would sign for their medications. EI #20 said RI #12's [MEDICATION NAME] was delivered to the facility on [DATE]. EI #20 said RI #12's [MEDICATION NAME] was deliverer to nursing station II and RI #12 had moved to nursing station I. EI #20 said the nurse on nursing station I should have walked to nursing station II to see if the medications were there. EI #20 said since RI #12 had a physician's orders [REDACTED].#12 did not receive the [MEDICATION NAME] at 4:00 p.m. and 9:00 p.m. on 09/10/17, the Physicians orders were not followed. On 09/14/17 at 11:05 a.m., an interview was conducted with the DON, EI #2. The surveyor asked EI #2, if a residents medications were in the facility and the nurse failed to give the medications, were the Physician orders [REDACTED].#2 replied, No, not if they (the resident) did not receive the medication. This deficiency was cited as a result of the investigation of complaint/report number AL 329.