Every finding on record at Clifton Heights

Based on observation, interview, and record review the facility failed to maintain a sanitary and safe physical environment to help prevent the presence of pests within resident care areas. interviews and observations during survey revealed concerns with the presence of pests.The findings include:Review of facility policy, Pest Control Program, implemented, 02/01/2024, revealed a local contractor provided preventative treatment monthly and as needed. Further review revealed the most recent treatment provided by the contractor was on 09/19/2025. Observations revealed insect/pest activity/residue in resident rooms and/or resident care areas during environmental rounds. Evidence of ongoing pest (insect) presence observed with pest residue recurring in reports noted upon re-entry after prior treatment last documented pest control entry 09/18/2025.Observations during survey, on 09/18/2025 at approximately 9:00AM and 09/19/2025, approximately 9:00 AM revealed insect carcasses (appeared to be cockroaches) in resident room [ROOM NUMBER], the dining area and the common area. Additionally, evidence of pests with insect residue observed in resident rooms 220, 222,223 and 225. Interview with Certified Nursing Assistant (CNA)3 on 09/19/2025 at 1:30 PM revealed roach activity was observed daily during the previous month on the North Unit, specifically in rooms 200 Hall, 220,222, 223, and 225.CNA3 reported observing pests crawling on walls and stated residents were aware of the pest infestation. CNA #3 confirmed pest control services were provided, however pests persisted.Interview with Certified Medication Technician (CMT)2 on 09/20/2025 at 2:30 PM revealed no direct observation of pests in resident rooms but acknowledged pest presence within facility common areas.Interview with Maintenance Director on 09/19/2025 at 1:45 PM, revealed the presence of a contract with a vendor to provide pest control services monthly and as needed. Further interview with the Maintenance Director no knowledge of pests in common areas or resident rooms.Interview with the Director of Nursing, on 09/19/2025 at 3:30 PM, revealed she was aware of a pest control contract. The Director of Nursing stated she had nothing to do with pest control but she was aware of pests' infestations. She further stated that pests could harbor and transmit diseases to residents.Interview with the Administrator, on 09/19/2025 at 3:00 PM, revealed the facility contracted with a vendor to provide pest control preventative treatment monthly and as needed. When asked why engage in pest control and the consequences of not doing so, the Administrator stated pests could harbor and transmit diseases to residents.

Based on observation, interview, and record review, the facility failed to ensure that a resident requiring tracheotomy care received treatment and services in accordance with professional standards of practice, the resident's care plan, and facility policy. The failure had the potential to result in respiratory complications, infections, and compromised airway safety for 1 of 3 sampled residents, Resident(R)32.The findings include:Review of facility policy, Tracheostomy Care Education, dated 2013, revealed tracheostomy care is the process of aseptically cleaning the tracheostomy tube and stoma site. Additionally, the policy indicated to follow relevant infection control procedures as appropriate.Review of facility record revealed the facility admitted R32 on 05/16/2025 with diagnoses including tracheostomy status, epilepsy unspecified, dysphagia, gastrostomy status. The facility assessed R32 on 06/14/2025 with a Brief Interview for Mental Status (BIMS) score of 5, indicating impaired cognition. During observation of tracheostomy care on 10/02/2025 at approximately 11:06 AM for R32, Licensed Practical Nurse (LPN) 2 failed to maintain clean/sterile technique when she identified her right hand as her dirty hand and used that hand to turn up the oxygen to hyper-oxygenate the resident, making the right hand no longer sterile. She then attempted to open the bottle of normal saline with her left hand and realized she was unable to do it with just one hand and twisted the top of normal saline with her right hand while holding the bottle with her left hand. Not realizing she broke sterile field; she poured the sterile water into kit to be used.During tracheostomy care LPN 2 failed to oxygenate or hyper-oxygenate the resident between suction passes, based on review of an evidence-based nursing reference Lippincott procedures Tracheostomy as required by respiratory-are standards resulting in increased risk for hypoxia and airway comprise. LPN2 removed the oxygen mask from the tracheostomy, and she inserted the suction catheter into the tracheostomy and began to suction R32. She completed three consecutive passes of suctioning without providing rest periods or assessing R32 respiratory tolerance. During an interview with LPN #2 on 10/02/2025 at approximately 11:29 AM she stated, I know I broke sterile field, and I did not oxygenate R32 in between passes. When asked why she did not do these things she stated, I know that I'm supposed to, I just got nervous. When asked if she should clean her working area or place a barrier for sterile procedures, she stated she is supposed to, but her nerves just got the best of her. When asked what some negative outcomes could be for residents, she stated resident could get pneumonia, aspirate or their tube could get messed up. The LPN stated I just started 3 weeks ago and got training when I first started, and I think we will have them yearly.During an interview with RN #2 when asked to describe the process for tracheostomy care, RN #2 reviewed the process verbally with no concerns noted regarding process or infection control. During an interview with Assistant Director of Nursing (ADON) on 10/02/2025 at 12:45 PM, she stated she was familiar with tracheostomy care process. When asked about the process when the sterile field was compromised the ADON stated the process would be to restart the process to provide safe and efficient patient care. Additionally, the ADON stated following the process was to prevent infectious disease or harming the resident.

Based on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure an effective pain management regimen, based on a thorough assessment and a person-centered care plan, was implemented for 1 of 11 sampled residents receiving scheduled pain medications (Resident (R) 1). The facility failed to administer pain medication as ordered to R1, who had a history of chronic pain and required multiple daily doses of a potent opioid analgesic. The failure created ongoing, severe pain, and R1 also experienced withdrawal symptoms which he described as, The only way the pain was going away was if I died.The findings include:Review of the facility's policy titled Pain Management, dated [DATE], revealed the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy states that, in order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated, evaluate the resident for pain and the cause(s) upon admission and with changes in condition, and manage or prevent pain, consistent with the comprehensive assessment and plan of care. and the resident's goals and preferences.The policy, dated [DATE], further revealed that, based on professional standards of practice, an assessment or evaluation of pain by the interdisciplinary team may include obtaining the resident's history of pain and its treatment, identifying key characteristics of the pain such as duration of pain, timing, pattern, and radiation, determining the impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood), and reviewing current prescribed pain medications, dosage and frequency. In the section on pain management and treatment, the policy stated that, based upon the evaluation, the facility, in collaboration with the attending prescriber and other health care professionals and the resident and/or representative, will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission, and that the interventions for pain management will be incorporated into the components of the comprehensive care plan. The policy further indicates that pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain, and that the interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, including evaluating the resident's medical condition and current medication regimen and using the most effective and least invasive route for analgesic administration.Review of the facility's policy titled Controlled Substance Administration and Accountability, revised [DATE], revealed that non-stock controlled substances are dispensed from the pharmacy according to physician orders for a specific patient. Review of the facility's policy titled, Medication Reconciliation, revised [DATE] revealed that, prior to admission, staff are to obtain the current medication list from the referral source (e.g., hospital, home health, hospice, or primary care provider), obtain current medication and admission orders, verify resident identifiers, and forward the information to the nursing unit accepting the resident. The same policy further specifies that upon admission staff are to verify resident identifiers on the information received, compare admission orders to hospital records and obtain clarification orders as needed, transcribe orders in accordance with procedures for admission orders, have a second nurse review the transcribed orders for accuracy and cosign to indicate the review, and order medications from the pharmacy in accordance with facility procedures for ordering medications.1. Review of R1's hospital History and Physical [H and P] revealed the hospital admitted R1 on [DATE]. Per the H and P, R1 had a history of a gunshot wound with residual paraplegia (paralysis of the lower limbs). The resident also had a chronic Stage IV pressure ulcer with osteomyelitis growing multiple drug-resistant organisms (MDRO.) This pressure ulcer was described as enlarging, with progressed loss of bone mineral density of the sacrum. The H and P noted that the resident had chronic pain and had orders for hydromorphone (Dilaudid - a potent opioid analgesic used to treat moderate to severe pain) both prior to admission, as well as during his hospitalization. Review of the facility's Discharge summary dated [DATE] at 1:53 PM revealed that R1 was discharged from the hospital to a nursing facility on [DATE]. R1, who was followed by a pain clinician (both prior to and during hospitalization), had medication orders at the time of discharge for Hydromorphone HCl oral table 2 milligrams (mg), two tablets every four hours for pain.Review of R1's admission Record revealed the facility admitted the resident from the hospital on [DATE], with diagnoses including paraplegia, muscle weakness, a sacral pressure ulcer, depression, and anxiety. Review of R1's Physician Orders, dated [DATE], revealed a routine order for Hydromorphone HCl oral tablet 2 mg, two tablets by mouth every four hours for pain (total of six med passes per day, for a total of 24 mg.) Review of the facility's Nursing admission Evaluation and Baseline Care Plan form, dated [DATE] at 6:32 PM and completed by Unit Manager (UM) 1, revealed that R1 displayed pain to the coccyx, which was described as throbbing. The narrative Progress Note section of the admission Assessment form documented the pain as an 8 (on a scale of 0 -10, with 10 being most severe pain) r/t [related to] sacral area wound and stomach per RSD [resident]. Further review of the admission Evaluation revealed that the nurse documented that R1's pain was acute (onset of less than 30 days) and did not address that the resident had chronic (ongoing) use of Hydromorphone, even prior to his hospitalization. Under the Pain Management Interventions Implemented portion of the form, the nurse completing the admission Assessment marked repositioning and non-pharmacological interventions (none specified.) Although R1 had admission orders for Hydromorphone and the assessment documented R1 had pain medication dependence neither Pain Medication Administered nor Notified MD/NP [doctor/Nurse Practitioner] was marked as implemented. Review of the Care Planning portion of the Nursing admission Evaluation and Baseline Care Plan, the nurse marked the need to Anticipate the resident's need for pain relief and respond promptly to any complaints of pain, offer non-pharmacological approaches and notify the physician if interventions were unsuccessful. The nurse also checked the interventions to identify what aggravated the resident's pain as well as what alleviated it; however, she failed to follow the instructions to specify this information, leaving it blank. Further review of the Care Planning Section revealed that the nurse completing the baseline care plan failed to identify the need to administer analgesia (specify medication) as per orders, monitor for non-verbal signs of pain, or monitor/record/report to the nurse when resident complaints of pain or requests for pain treatment. Although R1's Physician Orders dated [DATE] called for Hydromorphone HCl oral tablet every four hours for pain, review of the Medication Administration Record (MAR) revealed R1 did not receive the first dose of Hydromorphone until [DATE] at 8:00 PM, two days after admission. Interview with the dispensing pharmacy on [DATE] at 11:54 AM revealed that they did not receive any orders for Hydromorphone until [DATE] at 11:36 AM, when the Medical Director (R1's attending physician) first contacted them.Review of facility documentation revealed that during the two days the resident failed to receive his Hydromorphone as ordered, he suffered severe pain. In addition to the entry by UM1 dated [DATE] at 6:32 PM, documenting R1's pain at an 8/10, other documentation included:[DATE] Progress Note by Certified Nursing Assistant (CNA) 2 at 4:38 AM with pain at 8/10. [DATE] Pain rating in the MAR at 9/10 at 3:13 PM [DATE] Progress Note by Licensed Practical Nurse (LPN) 2 at 5:19 PM documented his pain at a 9/10. [DATE] at 10:05 PM Progress Note by UM1 documented the resident stated he wanted pain medication and had been told it Would be in soon. [DATE] Skilled Daily Note by UM1 at 11:45 PM stated: RSD complains of pain to nursing staff. RSD is lethargic and sleeps, then awake to alert nurse to symptoms of painXXX[DATE] Progress Note by the Nurse Practitioner (NP) at 12:59 AM stated: Patient complains of pain in back and legs, severe and waiting for pain medications. Complains of bilateral leg muscle spasms that are usually controlled with medication but has not had any. [DATE] Pain Rating in the MAR at 12:35 AM was rated 10/10XXX[DATE] note by CNA2 at 9:08 AM stated: RSD voiced c/o to staff regarding AMA (against medical advice) r/t (related to) pain and discomfort and medication unavailable.Nurse spoke with pharmacy regarding medications as well as NP. regarding a script for the hydromorphone. Dr [Medical Director] has been notified by nurse as well regarding hydromorphone.Review of R1's progress notes from [DATE] through [DATE] showed nursing staff contacted the NP, the Advanced Practice Registered Nurse (APRN), and/or Medical Director multiple times regarding R1's uncontrolled pain and the need for his Hydromorphone during the two-day period between admission and his first dose. A [DATE] progress note by UM2 at 12:13 AM documented: Medications verified with [NP]. At 2:50 AM on [DATE], CNA2 documented the order for Hydromorphone HCL oral tablet 2 mg. Give 2 tablets by mouth every 4 hours for pain, noting that the medication is unavailable at this time. RSD is new admission. RSD, provider and pharmacy [are] aware. At 12:21 PM, LPN2 documented she spoke with the APRN, regarding narcotic medication new scripts needed regarding hydromorphone, gabapentin and clonazepam orders. In response, documentation revealed that the APRN would give a one-time dose of Norco (a different, less powerful opioid). Per the note, the Medical Director was contacted regarding scripts, and the pharmacy was called regarding the medications. At 1:51 PM, she further documented: This nurse spoke with [NP] regarding resident pain medication. New orders for Norco 10 every 6 hrs PRN for pain until Dilaudid comes in. Resident is aware and voiced understanding regarding pain medication. On [DATE] at 9:08 AM, CNA2 documented in the progress notes that nursing staff had spoken with the pharmacy, NP, and Medical Director regarding the script for Hydromorphone.Review of R1's Physician Orders revealed that although the additional order was given on [DATE] at 3:15 PM for Hydrocodone-Acetaminophen oral tablet 10-325 mg, one tablet by mouth every six hours as needed for pain for two days, per the MAR, the medication was only given three times - [DATE] at 3:13 PM and on [DATE] at 12:35 AM and 5:20 PM. In an interview with R1 on [DATE] at 11:49 AM, he stated that he was seen by a pain clinic and was on Hydromorphone when he was at home, as well as in the hospital prior to admission to the facility. R1 stated, I arrived [to the facility] around 10:00 PM on [DATE] and [the facility] had none of my meds. I received my first dose [of Hydromorphone] late the second day. My body went into shock. He continued to say, Nobody was checking on me. I was going through withdrawals. I was crying. The withdrawals make you want to die; make you want to commit suicide. The only way the pain was going away was if I died. The nurses kept telling me the meds were coming. Finally, I said I need to go to the hospital. I was crying and vomiting and no one cared. I was told the reason for the delay in the facility receiving my [Hydromorphone] was the doctor didn't put the script into the pharmacy. There was no order placed to the pharmacy. Review of R1's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. Attempts to interview UM1 who completed the admission Assessment and Baseline Care Planning document were unsuccessful, as UM1 was no longer employed by the facility and did not have a working phone number.In an interview with RN1 on [DATE] at 1:01 PM, she stated she recalled R1's admission, his uncontrolled pain, and the Hydromorphone delay. Though she was unsure of the cause of the delay, she stated: [Hydromorphone] is not something we keep in the EDK and recalled speaking with UM1 about the issue. She detailed: I spoke with [UM1], made multiple calls to pharmacy and I may have talked to the [Medical Director] but if not, I know I spoke with [UM1] who should have talked to him. Sometimes we have issues where we notify the [Medical Director], we need something, but they don't get it ready. That could have been the issue, but I am not sure. When asked why R1 only received three doses of Hydrocodone between when it was ordered in the afternoon of [DATE] and when he received his first dose of Hydromorphone the following evening on [DATE], she stated: The only thing I can think of, and I am guessing, is we may have been getting them from the EDK (Emergency Medicine Kit). Sometimes there is two to three in the EDK. It depends on what is going on. It could also be that we were running short.In an interview with RN2 on [DATE] at 2:40 PM, she stated she did not recall R1's admission to the facility. She explained the admission process, stating that, When we get a new admission, we review the paperwork [the resident] brings with them, like if it was a discharge or something. We call the NP to go over the orders. I will verify the orders and then put the orders in. That would happen day one, within the first few hours of their arrival. She added that, If they have narcotics, we have to get an [Electronic Script]. I will let the [Medical Director] know we need the script and then I will call the pharmacy within 20 minutes or so to confirm they received it. RN2 stated that this was the same process used for after-hours admissions. She further stated that the process was the same for after-hours admissions, explaining, You can still talk to someone at the pharmacy so no matter what time they're admitted , the process is still the same. When asked about the facility's pre-admission processes, she stated, Some hospitals call and give report, but not all do. Some hospitals will fax over the scripts, some send it with EMS (Emergency Medical Services), and it is brought with [the resident] that way. If the hospital does not call to give report, you can call the hospital and try to locate the nurse to get a report.In an interview with LPN2 on [DATE] at 3:05 PM, she stated the facility's process for new admission orders consisted of verifying the orders with the Medical Director and calling the pharmacy to have medications sent stat [immediately].In an interview with UM2 on [DATE] at 4:25 PM, she recalled assisting with R1's admission, stating she double checked [R1's] orders when he arrived and reached out to the NP to get med approvals for his prescriptions, but could not recall what caused his Hydromorphone to be delayed.During further interview of LPN2 on [DATE] at 3:05 PM, she stated, I spoke with [the Medical Director] and the NP and called the pharmacy. I told them he needs something for pain to cover him. At first, they said to wait for the [Hydromorphone] to come. I said he is going to start having withdrawals. They didn't want to do anything until he said he wanted to go back to the hospital. I spoke to [the Medical Director] and he said he was faxing the order (to the pharmacy). I was trying really hard to get his pain medication. I made multiple progress notes. Regarding the delay in obtaining R1's Hydromorphone, LPN2 stated, The pharmacy said they didn't get the script. I was texting people, calling, and talking to administration. She added, His [the Resident's] pain was very intense.In an interview with the NP on [DATE] at 10:07 AM, she detailed the following regarding the facility's new admission order process for residents discharging to the facility from the hospital: When the resident gets here, we have an EDK we can pull meds from. We pull their meds from the discharge summary and send them to the pharmacy. The pharmacy then sends them over. She added, With Schedule 2 meds [narcotics], they have to go through our [Medical Director] because I am a NP. The nurses know it has to go directly to him. They can text or call him. He then sends it to the pharmacy. The NP recalled the delay of R1's Hydromorphone order and explained, Sometimes the hospital will send scripts straight to our pharmacy. For Schedule 2 meds it is usually a 3-day supply, but it's not consistent, it is hit or miss. In his case, it was not sent. She then reported: They (staff) told me they were just waiting for [R1's Hydromorphone] to arrive from the pharmacy. That is when I stepped in and wrote a script for Hydrocodone and had it pulled from the EDK. I had a conversation with [R1] about it and he was okay with that.During an interview with the Medical Director on [DATE] at 3:30 PM, he stated he did not recall staff reaching out to him several times regarding a need for an order for R1's Hydromorphone, and added, If they had reached out to me on the 15th (day of R1's admission) I would have done it [written the script] then. And if I missed it and they followed up with me, I would have done it. Even if I haven't seen them and the hospital prescribed it, I would prescribe it, so they don't suffer. The Medical Director further stated the NP could have prescribed the Hydromorphone. He explained the Drug Enforcement Administration (DEA) permits an NP to write up to 72 hours' worth of Schedule 2 drugs and added he would have had no problem with her doing that. In a subsequent interview with the Medical Director on [DATE] at 2:57 PM, he described the facility's new admission order process for hospital discharges as like, Opening Pandora's box. He explained: The hospital is supposed to send 72 hours of pain medication for the resident, but the hospital doctor does not. He elaborated that, as a result, [I] have to write [prescriptions] for someone I haven't even seen, adding: In good faith I write the scripts. I do it all the time for the betterment of patients' lives. When asked about the response time from when nursing staff reach out to him about a needed order and when he submits it to the pharmacy, he stated: 12 to 24 hours at the most; sometimes it is like two seconds. It is not difficult.Further interview with the Medical Director revealed he could not recall any specifics regarding the delay of R1's Hydromorphone. He stated: I am unsure of the timeline. My understanding is he got hydrocodone from the EDK. No nursing home has an onsite pharmacy, they have an EDK, and it contains six meds and does not include Hydromorphone. They can call me or call the NP to keep him comfortable with whatever they have in the EDK. When asked about the process if the EDK medication is not effective in keeping the resident comfortable, he responded: We can escalate meds. Someone can reach out to me, and I can write it. When asked if Hydrocodone would be effective in the place of Hydromorphone, he stated: It is not a substitute; you may not get 100 percent relief but you're not going to go into withdrawal. That's under the assumption that they are getting that PRN every 6 hours.Interview on [DATE] at 2:33 PM with a representative of R1's pain clinic revealed that he was a long-term patient and was seen for pain relief, both when the resident was living at home, as well as, for consultation during his hospitalization. The representative stated that no one had reached out to them for assistance with the resident's pain management.An interview was conducted with Registered Pharmacist (RPH) 1, from the facility's pharmacy on [DATE] at 2:13 PM. When asked about the potential consequences of a 48-hour gap between Hydromorphone doses, he stated: Pain management would be shot. To go from receiving Hydromorphone to zero, within hours of that last dose he would begin experiencing some degree of withdrawal and it would get worse with time. He explained that the two medications (Hydromorphone and Hydrocodone) were not equivalent, noting, Hydrocodone is a 1/5 ratio as far as equal analgesic conversion and that is documented. Five milligrams of Hydrocodone is equivalent to 1 mg of Hydromorphone. Regarding R1's severe pain ratings, he stated: Pain is subjective, but I can understand based on my knowledge of that medication his report of pain. That makes sense from a clinical perspective.In an interview with the DON on [DATE] at 3:39 PM, she stated she could not speak to the specifics of R1's admission as she has only been employed by the facility for approximately two weeks. She reported she has been trying to work together with the NP if the person needs a script before they get here. The NP refers staff to [the Medical Director] if she cannot write it. Regarding her expectations for the timeliness of admission orders, she stated: You can get medications stat delivered; you can also use the EDK if the med is available [in the EDK], but reported she was not sure about the actual timeframes for resident admissions, sending orders to the pharmacy, and receiving those orders from the pharmacy. The DON stated she did not consider a 48-hour delay to be timely. Interview with the Administrator on [DATE] at 9:25 AM, revealed his statement that R1 was admitted on [DATE] sometime between 9:00 PM and 11:00 PM and he provided no explanation as why or how the staff documented that they had completed an initial admission assessment on [DATE] at 6:32 PM.In an additional interview with the Administrator on [DATE] at 2:03 PM, he reported resident medications are taken into consideration prior to admission to the facility, stating they consider the availability, the costs, [and] whether it is a rare medication. Regarding the admission process for residents discharging from the hospital, he stated: We have a nurse liaison in the field. They receive referrals from the hospital. At times they go into the hospital and review the charts, talk to the resident. However, he was uncertain if this had taken place prior to R1's admission to the facility. When asked whether it was his expectation that scheduled medications be available when a new resident arrives to the facility, he stated: I expect us to follow our own policies and CMS guidelines. When asked if, for medications not on hand, the facility attempts to obtain them prior to the resident's arrival, he responded it depends on what the order is and our policies and CMS guidelines.Further interview with the Administrator, on [DATE], regarding his expectation for the timely administration of scheduled pain medication, he stated: Whatever our policies state and CMS guidelines. That would be something that a clinician would need to answer, but expressed that his expectation was that the physician orders were followed. When asked whether approximately 48 hours without a resident's scheduled pain medication would be considered timely, he stated: Depends. It is case by case. I would have to speak with the doctor. When asked about his expectation of appropriate pain management, he stated: I cannot answer that as I am not a clinician, then added: I would expect the clinician to address a resident's pain. The Administrator described the Medical Director's role at the facility as the overall clinician. The Administrator stated that it was on a case by case basis as to when in the admission process staff should reach out to the Medical Director to obtain scheduled medications, adding I did not see his referral, I don't know what medications he [R1] was on, I cannot speak to that.

Based on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure that 1 of 11 (Resident (R)1) sampled residents received diagnostic x-ray services in a timely manner, which created a delay in reporting any abnormal results to the physician and/or Nurse Practitioner, who had ordered the x-ray. After R1 sustained a fall, the facility failed to ensure that the resident received necessary follow-up, including implementation of physician orders for bilateral lower extremity (BLE) X-rays. R1 reported having severe leg pain and displayed swelling, changes in condition, and was eventually found to have a displaced tibia and fibula fracture that remained undiagnosed for approximately three days after his fall. R1 ultimately required surgery and 10 days of hospitalization in response. The findings include:Review of the facility's policy titled Verbal Orders, revised 02/14/2024, revealed that Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Per the policy, staff are to enter the order into the medical record electronically or manually, if needed, and follow through with orders by making appropriate notifications to the required provider.Review of R1's admission Record revealed the facility admitted the resident from the hospital on [DATE], with diagnoses including paraplegia and muscle weakness.Review of a Change in Condition (CIC) evaluation, dated 10/29/2025 at 11:37 PM and documented by Licensed Practical Nurse (LPN) 3, revealed that R1 sustained a fall. Under Nursing observations, evaluation, and recommendations, the note documented the resident stated his feet were awkward in position. In response, the Nurse Practitioner (NP) provided a new, verbal order for X-rays to the bilateral lower extremities (BLE), with orders received and noted. The provider feedback section of this form documented new testing orders for an X-ray to the BLE and to continue to monitor.Review of R1's progress notes for the remainder of 10/2025 revealed no further information regarding the need for X-rays. An entry dated 10/31/2025 at 3:53 AM by Registered Nurse (RN) 4 documented the resident told the nurse he had fallen two days ago, and RN4 instructed the incoming nurse to follow up and report to the NP in the morning; however, the note failed to address that X-rays were ordered but had not been obtained. A progress note dated 11/01/2025 by LPN3 documented the resident complained that both feet appeared awkward and that the nurse encouraged the resident to go to the hospital for evaluation; however, the resident declined at that time, stating: I'm ok, I'll be ok until I get back. There was no evidence that the order for the X-rays was acted upon, or that staff identified that it had not yet been completed. Further review of the record revealed a CIC evaluation, dated 11/01/2025 at 11:15 PM, and documented by the Infection Preventionist/Staff Development Coordinator (IP/SDC). The note documented the resident complained of severe [right] leg pain from the thigh down to the foot. Per the note, the resident's pain was rated at 9/10 (with 0 meaning no pain, and 10 being worst pain imaginable), and that after receiving his bedtime medication pass, he was still inconsolable. The nurse assessed the leg and noted it was notably more swollen than [the] other extremity. The note documented the resident requested to go to the hospital and approached the nurse fully dressed with face flushed and red, grimacing, holding onto leg. The entry further reflected the resident stated, An X-ray was ordered but company never came, and the nurse was extremely concerned about [the] patient's disposition, not being at baseline and the possibility of a deep vein thrombosis (DVT) worsening and dislodging into his blood stream due to patient history. The note documented the resident stated the pain was getting worse and worse over the course of the past few days, and the nurse decided based upon the findings that an emergency send was warranted based upon [the] patient's [resident's] request. Vital signs obtained at that time included elevated blood pressure (186/95) and pulse (105). The entry documented the resident's change in condition included uncontrolled pain and elevated vital signs, that the NP and Director of Nursing (DON) were notified, the emergency contact was notified, and report was called to the hospital.A progress note dated 11/01/2025 at 11:26 PM documented the IP/SDC spoke with an RN at the hospital's emergency room, who reported the resident would likely be admitted and that imaging had identified a displaced fracture of the tibia and fibula, with the bone having shifted. The note documented that the DON and Medical Director were notified of these findings. There was no evidence in the clinical record that the ordered BLE X-rays were completed at the facility prior to the resident's transfer on 11/01/2025, approximately 72 hours after the need for the X-ray was first identified.Review of the hospital Final Report, dated 11/11/2025, revealed the hospital admitted R1 on 11/01/2025 and discharged him back to the facility 10 days later, on 11/11/2025. Per the Final Report, the resident required surgery for a primary discharge diagnosis of tib-fib fracture, right. Review of the facility's fall incident report for the 10/29/2025 fall, completed by the Interim Director of Nursing (IDON) on 11/02/2025, and a written statement from LPN3 dated 11/02/2025, was consistent with the clinical record and interviews regarding the date and circumstances of the fall, the NP being notified, and the order for BLE X-rays.In an interview with R1 on 11/12/2025 at 11:49 AM, he stated the fall on 10/29/2025 occurred when he was trying to get to his wheelchair, and he fell from the bed onto the floor. He reported that after the fall, he remained in the facility until staff later arranged for him to be sent to the hospital by ambulance. R1 stated RN2 informed him that an order for a portable X-ray at the facility was given after his fall; however, the facility failed to obtain it, and the X-rays were not completed until after he was transferred to the hospital in severe pain. Review of R1's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/17/2025 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition.In an interview with the Administrator on 11/13/2025 at 11:04 AM, he stated R1 fell on [DATE] and that the NP placed an order for an X-ray. The Administrator stated he was under the impression [R1] did not want an X-ray, and that R1 told him he was going out with his family. He confirmed there was no documentation in the record that R1 had refused the portable X-ray and the Administrator acknowledged he did not verify that the ordered X-ray had been completed.During an additional interview with R1 on 11/18/2025 at 12:12 PM, he denied that Administrator's allegation that he refused an X-ray. He stated: I didn't refuse an X-ray [on 10/29/2025]. I did not go out with my family [on 10/29/2025]. In an interview with LPN3 on 11/15/2025 at 8:53 PM, she stated the fall on 10/29/2025 occurred in the middle of the night. She stated Certified Nursing Assistants (CNAs) (she was unable to recall the specific CNAs) notified her that R1 was on the floor on the side of his bed, and staff assisted him off the floor with a Hoyer lift and back to bed. She stated that following the fall, R1 complained his foot was awkward. She stated the NP was notified after the fall, between midnight and 1 AM and that the NP agreed to a bilateral legs X-ray and ordered X-ray only. LPN3 was able to verbalize each of the steps in the protocol, explaining that staff should place [the] order in Point Click Care (PCC), print it, and place it on the nurse's cart until [the X-ray company] arrives. Then give them a copy, and that a progress note should be completed, with the nurse who puts the order in responsible for following up and passing that information on to the oncoming nurse in report. Although LPN3 was able to verbalize each of the steps, she stated she was not oriented on how to place an X-ray order, and so, instead, asked RN2 to place the order. Further interview with LPN3 revealed that after this, she was then off for a couple of days and did not follow up on whether the X-ray was completed when she returned, adding that she did not have [R1] as a patient [resident]. In an interview with RN2 on 11/13/2025 at 2:40 PM, she described her general process for verbal orders as: I would repeat it back to make sure it is correct and then put it in PCC. Regarding X-ray orders, she stated: Put it in PCC then call [the X-ray company]. Some people have access to put them in online, but I don't so I call, and stated she would definitely complete this within her shift and that documenting it in a progress note is important so everyone can know what is being done on previous shifts. She reported she was not working at the time of R1's 10/29/2025 fall and learned about it on the next shift from LPN3.In follow-up interviews with RN2 on 11/18/2025 at 1:00 PM and 11/19/2025 at 1:23 PM, she stated that with respect to R1's X-ray, [LPN3] did not know how to do it and asked her to place the X-ray order. She stated the Unit Manager (UM) used to put them in but we did not have one [a UM] at that point. She reported that neither she nor LPN3 had a login for the X-ray company's portal and that she therefore called them. She stated the X-ray company told her they could not find R1's name in their system and instructed her to go back and put it in PCC, and that she did what [they] said. She stated she did not call back and confirm the X-ray because it was the end of my shift, and that she passed the X-ray information on to the next nurse in report. She stated she did not get an X-ray order number. RN2 stated that LPN3 did not tell me he fell and just said he needed an X-ray. [he] was complaining of his legs. She stated she couldn't put a progress note regarding R1's pending X-ray because [she] had to leave, adding she, was trying to figure it out because the UM usually does it. She further stated this was the only one [X-ray order] I have ever done, that she was unsure who does them now, and that she did not clarify if [she] did it right. She stated it was her understanding that the nightshift nurse would be the one to follow up to confirm the X-ray got completed, and reported she was off for the next two days. In interviews with the X-ray company's staff on 11/18/2025 at 1:30 PM and 11/19/2025 at 2:13 PM, Customer Service Representatives stated they searched their system for R1 using his date of birth and various combinations of his last name and found no record at all, ever, of an X-ray order for this resident, meaning we never received an X-ray [request] for this resident. When asked whether they would tell a nurse who calls to order an X-ray that they could not proceed because the resident was not in [their] system and must first be entered via PCC, the representative stated that not being in their system would not be a roadblock to having an order placed with us over the phone, and that they would just add their name if they aren't in our system. The representative further stated that when an X-ray is ordered by phone, they provide an X-ray order number as confirmation, and confirmed that they had received no orders from the facility to provide a portable X-ray for R1.In interviews with LPN4 on 11/14/2025 at 4:02 PM, RN3 on 11/14/2025 at 3:00 PM, LPN5 on 11/17/2025 at 3:16 PM, and UM2 on 11/14/2025 at 4:25 PM, they were able to verbalize the process for verbal orders, as well as the need for progress notes for communication between shifts, and monitoring for follow up and completion of orders. In an interview with RN4 on 11/17/2025 at 3:00 PM, he stated R1 told him he had fallen a couple of days ago and that he had a little pain and he observed his leg to be a little swollen. He stated he passed it along but did not notify the NP himself, explaining it was in the middle of the night and that in his experience if it's not an emergency, we don't call the NP. Further interview revealed his Progress Note on 10/31/2025 at 3:53 AM did not mention a pending X-ray because he did not know one was pending. In an interview with the IP/SDC on 11/14/2025 at 12:22 PM, she stated that on 11/01/2025, R1 approached her on the unit complaining of severe leg pain and that she had not seen him earlier in her shift. She stated R1 reported an X-ray had been ordered but that they never came, and that based on his condition and complaints, she completed the 11/01/2025 change in condition assessment and arranged for him to be sent to the hospital. She stated clinical staff were responsible for following up on X-rays.In an interview with the NP on 11/13/2025 at 10:07 AM, she stated that on 10/29/2025 R1 fell out of bed and was complaining of leg pain, so she ordered a bilateral leg X-ray in response. She stated that she did not order the X-ray stat (with an expected time frame of four hours.) Instead, it was a routine order, for which she believed that 24 hours is reasonable. Further interview revealed she looked in the computer to see whether orders such as X-rays had been completed and that if something was not done, nursing staff or the UM would usually follow up with her. The NP reported that by the time she would have known there was an issue with not obtaining R1's X-ray, He had gone to the hospital. In a follow-up interview on 11/21/2025 at 12:54 PM, when asked who staff should reach out to at night for provider issues, she stated: It is me.In an interview with the DON on 11/17/2025 at 4:02 PM, she stated there was a form used for auditing and oversight of orders and believed It is being used during the clinical meeting, which is held daily, adding whoever is leading the meeting that day would fill it out. She stated presently she is the one reviewing charts to make sure there are no pending orders, but that she was not working at the facility at the time of R1's X-ray order and could not identify who was responsible for ensuring his ordered X-ray was completed and followed up during that period, and was unable to provide evidence that the chart had been audited to identify the pending order. In a subsequent interview on 11/21/2025 at 3:44 PM, she stated nurses that have been trained can order X-rays but acknowledged there were recent changes in the process for ordering X-rays and that a lot of staff, including her, were new. She stated a staff member could confirm an X-ray had been ordered correctly by calling [the X-ray company] for confirmation. She stated possible routes for ordering an X-ray included calling it in, placing it in PCC, or going into the X-ray company's system, and that follow-up to ensure X-rays were completed should be passed in report from nurse to nurse. The DON was unable to say whether there was any follow up on R1's X-ray, adding, I was not here during that time.In an interview with the Administrator on 11/21/2025 at 2:03 PM, he stated practitioners, such as doctors and NPs, and nurses that have been trained have the ability to order X-rays. When asked how staff confirm an X-ray had been ordered correctly, he stated, I do not know that process, then added The clinicians would know. He stated leadership, the clinical team, and the Interdisciplinary Team [IDT] follow up that X-rays are completed. The Administrator again repeated that he was under the impression that R1 did not want an X-ray and told him he was going out with his family; however, he then acknowledged there was no such documented refusal.

Based on interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for six (6) out of thirty-nine (39) sampled residents. (Resident #7, Resident #4, Resident #70, Resident #15, Resident #89, and Resident 46). 1. The facility failed to protect Resident #7 from abuse. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. The facility, however, failed to protect the resident from abuse and continued to allow the staff member to work, gaining access to the resident to potentially abuse the resident further. Subsequently, on 07/26/2023, Resident #7 reported to the facility staff allegations of sexual abuse when Certified Nursing Assistant (CNA) #24, would come into his/her shower room while he/she was undressed, which made him/her feel uncomfortable and harassed. 2. On 07/24/2023, Resident #4 and Resident #70 reported to staff that Resident #3 made vulgar comments to them. Interviews with the residents and staff revealed there was no supervision in the dining room to prevent the verbal abuse. 3. On 02/18/2023, Resident #20, picked a cup of water off the medication cart and threw the water onto Resident #15's upper body. Interview with staff revealed Resident #20 required supervision and monitoring to prevent physical abuse to other residents. 4. On 07/11/2023, Resident #12 kicked Resident #89 in the leg while waiting to go outside to smoke. 5. On 07/15/2023, Resident #19 attempted to throw his/her bedside table at Resident #46, his/her roommate, and grabbed Resident #46's arm instead. 6. On 08/03/2023, Resident #70 hit Resident #39 with a plastic bag when Resident #39 refused to give Resident #70 a coke. The facility's failure to ensure residents were protected from abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/29/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a K and (F607, F609), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600, F607, and F609). The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is Ongoing. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, undated, revealed: all residents were to be protected from harm; the Executive Director was responsible for oversight of abuse prohibition standards; and all allegations involving staff would necessitate suspension pending investigation. Per review of the policy, the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review revealed abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychological well-being. The policy review revealed instances of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Continued review of the facility's policy, Freedom from Abuse and Neglect, undated, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Further review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Per review, types of abuse would include humiliation, harassment, threats, punishment, or deprivation, taking unauthorized resident photos or video recordings, posting of ANY resident photos, video recordings or other resident information on social media networks. Further review revealed rape or other sexual abuse included: sexual harassment, sexual assault, and sexual coercion. Review of the facility's policy titled, Abuse Prevention Program, revised December 2016, revealed it was the facility's policy that residents had the right to be free from abuse. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. Continued review revealed as part of the resident abuse prevention, the administration would protect residents from abuse which included facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of a document titled, Lotus, Pathway to Addition and Recovery undated, revealed the goal of the program was to build a community that provided each resident with a safe, drug-free, environment that promoted health and healing. A continued review of the document revealed staff was to cultivate a caring, sober environment. Further review revealed the resident waived his/her normal privacy standards as part of the drug and alcohol treatment (ARC) program when admitted to the facility on [DATE]. This included but was not limited to, scheduled visitations would be virtual visits only, a phone would be available for use for personal telephone communication, random drug screenings would be completed, personal items would be searched in view of the resident, and no sexual activity. Further, the program was to provide a safe, therapeutic environment for all the residents. 1. Review of Resident #7's Admission Record revealed the facility admitted Resident #7 on 05/29/2023 with Diagnoses which included: Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description Note, dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed on 07/20/2023 the Executive Director (ED) received an anonymous call that Resident #7 was involved in a relationship with a staff member,with only first name given. The caller was unable to give a last name or description of the employee. The caller stated the resident and facility staff member had been texting and sending inappropriate pictures via text message. Resident #7 was interviewed at this time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. The Human Services Director (HSD) and DON interviewed all employees with the first name provided by the anonymous caller, and all denied any inappropriate relationship with a resident or sending inappropriate pictures. Continued review of the facility's investigation revealed the staff members matching the first name given were not suspended while the facility conducted its investigation. Further review of the facility's Alleged Abuse Investigation Nursing Incident Description Note, dated 07/26/2023 at 6:26 PM, entered by the DON, revealed on 07/26/2023 Resident #7 spoke with his/her Peer Support Specialist (PSS) and reported to him that he/she had not been honest when he/she was first interviewed and stated that he/she had a friendship with the agency's Certified Nursing Assistant (CNA) #24, and that he/she attempted to cut the friendship/relationship off, but the CNA would come to Resident #7's room and shower room, and this made him/her feel uncomfortable. Further review of the facility's investigation, dated 07/26/2023 at 6:26 PM, revealed Resident #7 reported he/she realized he/she was in a vulnerable state due to his/her sobriety and that he/she thought he/she could handle the situation on his/her own. Ongoing review of the Alleged Abuse Investigation revealed CNA #24 kept coming to his/her room and knock on his/her door. He/She further reported the CNA would come in the shower room when he/she did not require assistance. Resident #7 stated the CNA never physically touched him/her, but she made him/her feel uncomfortable. Review of Resident #7's Activities of Daily Living (ADL) Logs for July 2023 revealed CNA #24, who was assigned to the Lotus Unit, had charted she had provided care to Resident #7 on 07/04/2023, 07/16/2023, and 07/19/2023. Review of CNA #24's Clock In and Out Sheet revealed she had worked on Saturday 07/22/2023, from 7:00 AM - 7:00 PM, and on Sunday 07/23/2023, from 7:00 AM - 11:00 PM, which allowed the CNA access to the resident after an allegation of abuse was made on 07/20/2023, exposing the resident to continued potential abuse. Review of Resident #7's Psychiatric (Psych) Note, dated 07/26/2023, revealed the Psych Advanced Registered Nurse Practitioner (PARNP) saw Resident #7 at the request of the facility after inappropriate sexual behavior was reported. Resident #7 reported he/she was at the facility for rehabilitation after having spinal surgery. Resident #7 had approximately two (2) weeks left in the Lotus Addiction Recovery Program and reported one (1) facility staff member, who was a female, kept coming into his/her room multiple times throughout the day, even when he/she did not need his/her help. Continued review of the Note revealed Resident #7 reported the facility staff member would go into the shower room while he/she was taking a shower, even though he/she needed no assistance with showering. Continued review of the Psychiatric Note, dated 07/26/2023, revealed the resident reported that the staff member never touched him/her inappropriately but made him/her feel very uncomfortable. Resident #7 reported the staff member texted him/her multiple flirty comments and constantly followed him/her into the shower room, even when she was not supposed to be on his/her floor. Per the note, this happened multiple times over the past month. Additional review revealed after this was reported, the resident came clean in his/her own words, that CNA#24 had tried to be in the shower with him/her multiple times over the past month. Ongoing review of the Note revealed Resident #7 reported the CNA constantly harassed him/her throughout the night and would not let him/her sleep. During an interview with Resident #7, on 07/27/2023 at 9:00 AM, the resident stated Certified Nursing Assistant (CNA) #24 sent photos through a social media application of herself topless and showing her bare breasts, and the photos were deleted after twenty-four (24) hours. Resident #7 stated if he/she could retrieve the photos, he/she would send them to the State Survey Agency (SSA) surveyor, as proof. The resident, however, was unable to provide the pictures to the SSA surveyor prior to exiting the facility. Resident #7 stated that at first, he/she was friends with the CNA, and they began talking a lot. Per the interview, the resident stated the friendship was consensual as he/she did not have any family or friends and it was nice having someone close to talk to. Resident #7 stated the relationship progressed and CNA #24 kissed him/her which made the resident feel uncomfortable. Resident #7 stated he/she told CNA#24 he/she did not feel comfortable having that kind of relationship because he/she was in treatment for his/her addiction, and he/she needed to continue to work the program for recovery before having an intimate relationship with anyone. Further interview with Resident #7, on 07/27/2023 at 9:00 AM, he/she stated CNA#24 continued to send nude photos after being told to stop. The resident further stated the CNA would wake him/her up at all hours of the night coming into his/her room when she worked her shifts at the facility. Resident #7 stated he/she confided in two (2) residents (Resident #9 and Resident #13) on the Lotus Unit about his/her concerns and Resident #9 asked to see the photos. Per the interview, Resident #7 stated he/she showed the photos to the residents. Resident #7 stated he/she told Resident #9 and Resident #13 he/she told CNA#24 to stop sending text messages and photos, and that it was making him/her feel uncomfortable, harassed, embarrassed, and shameful, because she was coming into his/her room at night and entering the bathroom when he/she was unclothed, while showering. Resident #7 stated a rumor had gotten out all over the community about what was going on and the Director of Nursing (DON) and the Human Resource (HR) person called him/her into their offices to talk about the incidents. Resident #7 stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA# 24 in trouble. During an interview with Resident #13, on 07/27/2023 at 11:15 AM, he/she stated about three (3) days ago he/she noticed CNA #24 was after Resident #7 hot and heavy. Resident #13 stated Resident #7 told him/her the CNA had been sending him/her text messages and nude photos on his/her phone. Resident #13 stated he/she did not look at the text messages or photos, but stated every time Resident #7 went outside, the CNA would find a reason to go outside. Resident #13 stated that if Resident #7 was in the dining room, the CNA would come into the dining room. Resident #13 also stated the CNA smoked and was always asking Resident #7 to go outside and smoke with her, even though Resident #7 did not smoke. Resident #13 further stated, anywhere Resident #7 was, the CNA would find a reason to follow him/her. Resident #13 stated CNA #24 would not be back to work at the facility because when you mess with a resident, that was not a good reputation to have. During an interview with Resident #9, on 07/31/2023 at 3:00 PM, he/she stated CNA #24 and Resident #7 were friends; however, the CNA was a little extra with Resident #7. Per the interview, CNA #24 would come over to Resident #7's room even when she was not assigned to be on the unit. Further, the CNA would ask Resident #7 to go outside and smoke with her, even though the resident did not smoke. Resident #9 stated CNA #24 would stay over on her shifts to be near Resident #7. Per the interview, Resident #9 stated he/she never saw CNA #24 kiss Resident #7; however, stated Resident # 7 told him/her the CNA sent him/her nude pictures of herself and sent pictures of her family to Resident #7's phone. Resident #9 stated, I think she had a crush on Resident #7. Resident #9 stated Resident #7 told CNA #24 she needed to stop calling and texting him/her. Resident #9 stated he/she thought the CNA's behavior was very unprofessional and inappropriate. During an interview with CNA #24 on 07/28/2023 at 2:45 PM, she stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency for about two (2) months. CNA #24 stated she had worked all units including the Lotus unit. Per the interview, the CNA stated sexual abuse would be touching inappropriately, making someone feel uncomfortable, and that entering in the shower while a resident was showering would not be considered sexual unless it was intentional. CNA #24 stated she had heard rumors that she had a relationship with a resident, that she came on to Resident #7, and that she was showing favoritism to him/her. CNA #24 stated she would buy items for several residents who felt alone, like buying soda for a resident. CNA #24 stated Resident #7 stated he/she was all alone, and he/she hated to ask for help. The CNA stated Resident #7 would offer her his/her cash app (a mobile payment service) to buy On Pouches (nicotine pouches) because he/she was a dipper of tobacco, not a smoker. Further, she stated the resident was ask her to buy him/her soap. CNA #24 stated they were only friends. CNA #24 stated she had been texting Resident #7 and he/she would text her about how he/she felt. CNA #24 further stated Resident #7 sent her a picture of his/her daughter and a shirtless picture to show her he/she was gaining weight. In a continued interview, on 07/28/2023 at 2:45 PM, CNA #24 stated she sent Resident #7 pictures of herself and her kids, adding, they were family type pictures. CNA #24 denied she sent the resident nude pictures of her and denied kissing the resident. However, stated that now she has researched it, she realized maybe she should not have been texting or sending photos to Resident #7. CNA #24 stated she wished she had known that her friendship with Resident #7 was not appropriate and had been considered abuse based on the facility's policy. Further, the CNA stated she was informed by the DON that since her relationship with Resident #7 was consensual she was still hirable. The CNA stated she later received a call from the facility's Human Resource Director and DON stating she was not allowed to return to the facility. During a phone interview with Licensed Practical Nurse (LPN) #1, on 07/27/2023 at 8:00 PM, she stated she had been working the Lotus Unit since February 2023. LPN#1 stated that prior to working at the facility she had worked for fifteen (15) years at the jail and had a lot of experience working with Substance Abuse clients and had a lot of education in substance abuse, detox, mental illness, behaviors, and meth-induced psychosis. LPN #1 stated on 07/24/2023 she heard from staff members talking on the unit that something was going on between CNA #24 and Resident #7. LPN #1 stated her supervisor LPN #11 was there, and asked if it should be reported. The supervisor agreed it should be reported and made a call to the DON that night to report CNA #24 and Resident #7 were in a relationship. LPN #1 stated she and her supervisor, LPN #11, went to talk with Resident #7 and he/she reported he/she talked on the phone with CNA #24 and sent text messages and photos. The resident stated he/she decided to cut off the relationship/friendship, but CNA #24 started harassing him/her and invading his/her space. LPN #1 stated she had Resident #7 sign a statement about his/her relationship/friendship with the CNA, and she handed it to the Assistant Director of Nursing (ADON) at the end of her shift that morning. During an interview with Registered Nurse (RN) #3, on 07/27/23 at 8:50 PM, she stated she primarily worked the Lotus Unit and had been at the facility for almost two (2) years. RN #3 stated there was an inappropriate relationship between CNA #24 and Resident #7. Per the interview, RN #3 stated CNA #24 was pursuing Resident #7 and she was observed going to the resident's unit and into his/her room. RN #3 stated she heard about the inappropriate relationship about 2 weeks ago (the week of 07/10/2023) and told the DON. RN #3 stated the DON said she would take care of it; however, she could not see where anything had been done to address the allegation after she reported the incident to the DON. The RN stated a week went by and then she heard about the photos from Resident #9. RN #3 stated Resident #9 stated CNA #24 sent Resident #7 naked photos of herself. Per the interview, Resident #9 stated he saw the photos and text messages sent to Resident #7 on his/her phone. RN #3 stated after she reported the inappropriate relationship to the DON, she started to receive a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot of paperwork to redo and stated she was not doing her job. Per the interview, RN#3 stated, the facility did not protect Resident #7 from abuse. She further stated, in this case they treated Resident #7 like a perpetrator and said the resident had manipulated CNA#24 and she was the victim, not the resident. During an interview with LPN #11 on 07/28/2023 at 4:00 PM, she stated she worked as the night shift supervisor on the 11:00 PM - 7:00 AM shift Continued interview with LPN #11, she stated she heard staff talking about an aide (CNA #24) on the Lotus Unit was going into Resident #7's room when the aide was not assigned to work that unit and was calling the resident on phone. LPN #11 stated on the night shift on 07/23/2023, CNA #24 was assigned to work another unit. However, she kept seeing her coming in and out of Resident #7's room when she was not supposed to be on the unit. LPN #11 stated LPN #1 asked CNA #24 if she had been reassigned to work the Lotus Unit that night and CNA #24 stated no and left the unit. LPN #11 stated she and LPN #1 went to talk with Resident #7 about their relationship and he/she stated there was no relationship between him/her and CNA #24. LPN #1, who had a better rapport with Resident #7, asked LPN #11 to leave the room so she could talk to Resident #7. LPN #11 stated a few minutes later, LPN #1 called her back in the room and Resident #7 told LPN #11 he/she did have something going on with CNA #24, but he/she did not want it anymore because he/she was trying to get clean, but CNA #24 kept bothering him/her and kept coming into his/her room. The LPN stated Resident #7 stated he/she just wanted CNA #24 to leave him/her alone. Per interview, LPN #11 stated the facility did not protect Resident #7 from abuse. During an interview with the DON on 07/29/2023 at 2:47 PM, she stated she had been the DON at the facility since May 2023 and she had been educated on Abuse several times in the last few months by the Staff Development Coordinator (SDC). She stated calling, texting, and sending pictures to a resident would not be considered sexual abuse or inappropriate if the relationship was consensual. She further stated that on 07/20/2023, the Executive Director (ED) told her he had received an anonymous call on 07/20/2023 from a male caller who stated an employee, identified by first name, had been sending inappropriate pictures to a resident, identified by first name and last initial (Resident #7). The DON stated an investigation was initiated immediately by contacting the Human Resource Director (HRD) because they did not know who the employee was because they only had a first name. She stated she, the HRD, and the ED interviewed Resident #7 and he/she denied an inappropriate relationship had occurred. The DON then stated she and the HRD started interviewing all the staff members identified by the first name provided by the caller, and all the staff members interviewed denied having an inappropriate relationship with a resident, and denied texting, calling, or sending photos to a resident in the facility. Per the interview, no employees were suspended during the investigation because all had denied a relationship had occurred with a resident. Further interview with the DON, on 07/29/2023 at 2:47 PM, revealed Resident #7 later told his/her Peer Support Specialist (PSS) in the Lotus Program, that he/she had not told the truth to the DON and ED about exchanging phone calls, text messages, and photos with CNA#24. The DON stated after hearing the information provided by the PSS, she and the HRD called CNA #24 and she stated Resident #7 had pursued her and he/she had initiated the interaction with her. The DON stated she asked CNA #24 for copies of her text messages and CNA #24 sent them the next day, and there were only pictures of her in her bathing suit at the pool with her kids. She stated she asked CNA #24 why she did not come forward and report the relationship and she said because she and Resident #7 were just friends, and she did not think she was doing anything wrong. The DON stated she did not think Resident #7 was a victim, that he/she manipulated CNA #24. She then stated, she did not know why the facility should have reported the incident because the resident had a BIMS of fourteen (14), denied the allegations in the beginning, and had the right to a consensual relationship. Review of the facility's policy; however, revealed the resident had the right to be protected from abuse, to include staff members. Further, review of the Lotus Program document revealed the resident would be provided a safe and therapeutic environment. The facility failed to ensure its policy and procedures were followed to protect the resident from potential abuse. During an interview with the Regional Human Resource Business Partner (RHRBP) on 08/09/2023 at 10:43 AM, she stated she was involved in assisting the facility with investigations, compliance, and development of leadership in all the corporation's buildings. The RHRBP stated the ED had received a call on 07/20/2023 about a possible allegation of a resident having a relationship with a staff member that included nude pictures and was told the staff members first name, no last name, and the ED did not know what do. The RHRBP stated she told the ED she did not know the protocol, and that it might be a reportable incident. She stated she informed the ED and DON they needed to do whatever needed to be done based on policy. Further, she stated they needed to launch an investigation and the ED said how, I have vague information. The RHRBP stated she told the ED that he was provided the staff members first name, so have the DON pull a roster of staff members with the first name provided, both agency and facility staff, and begin interviewing all of them. She then stated she instructed the ED to also conduct an interview with Resident #7. The RHRBP stated she interviewed Resident #7 and all staff members with the first name provided by the anonymous caller, and all denied having an inappropriate relationship involving texting, phone calls, and nude photos. In a continued interview with the Regional Human Resource Business Partner (RHRBP), on 08/09/2023 at 10:43 AM, she stated she spoke with Certified Nursing Assistant (CNA) #24 and the CNA stated she was taken advantage of and was manipulated by Resident #7. Further, the RHRBP stated she told CNA #24 she made the decision to be in a relationship with the resident and the CNA cried, asking if she would lose her license. The RHRBP stated she asked the CNA if she had text messages from the resident and the CNA stated she had deleted them, at first, but later produced the text messages the next day. The RHRBP stated the facility failed to ensure its policies were followed. In terms of reporting the allegations of abuse, the RHRBP stated both allegations should have been reported to State Agencies. She further stated she was not aware the allegations had not been reported. During an interview with the Executive Director on 07/29/2023 at 1:55 PM, he stated on 07/20/2023 he received an anonymous call saying there were nude pictures sent to a resident (Resident #7) by a staff member identified by first name only, no last name was given. He stated after he received the call, he tried to figure out who the resident and the staff member were. The ED stated he notified the RHRBP who advised him to compile a list of all staff with the first name provided by the caller. The ED stated he interviewed Resident #7 and he/she denied anything had occurred. Per the interview, the facility did not send in a reportable on 07/20/2023. Further, the ED stated, after discussing the allegation made in the call with the Corporate [NAME] President of Operations (VPO), it was decided the allegation made on 07/20/2023 was not reportable. Review of the facility's policy related to abuse; however, revealed that all allegations related to abuse would be reported and the residents would be protected from abuse to include staff members. The ED, during the interview on 07/29/2023 at 1:55 PM, stated a 2nd allegation of abuse was reported involving the same individuals on 07/24/2023 and the DON and ED questioned Resident #7 again, and he/she again denied an inappropriate relationship with a staff member. The ED stated he again called the RHRBP to discuss what should be done about the allegation and was told it was not abuse and was not reportable because the resident denied it happened. The ED stated on 07/26/2023, Resident #7 then confided in his/her Peer Support Specialist (PSS) in the Lotus Program and a lot more information came out. After the second report came in on 07/26/2023, the Interdisciplinary Team (IDT) met as a Quality Assurance (QA) team and that's when it was determined to start an investigation. CNA #24 had her agency contract terminated because the facility's investigation determined the CNA had an inappropriate relationship and an inappropriate way to act with residents. The ED stated we felt the relationship became more personal with text messages being sent and the fact that she was seeing the resident in his/her room and shower when she was not assigned to work the Lotus Unit. He further stated he was not aware she had worked 2 more shifts at the facility after the 07/20/2023 allegation was made. The ED stated his expectation was for staff to follow the abuse policy process and report allegations of abuse immediately, without fear of retaliation, and he expected a full thorough investigation be conducted on all allegations of abuse. During an interview with the [NAME] President of Operations (VPO) on 07/29/2023 at 3:35 PM, he stated the 07/20/2023, an anonymous call regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS of 14, the resident was of sound mind, and the resident had the right to have a relationship of his/her choosing. Review of the facility's Lotus Program for substance abuse; however, revealed the resident signed a document upon admission which waived his/her rights to visitors, which would be virtual contact only, his/her phone, as one would be available for use for personal telephone communications, and sexual activity, while being a resident within the facility. Further, the program stated the resident would be provided a safe, therapeutic environment. In a continued interview with the VPO, on 07/29/2023 at 3:35 PM, Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. Per the interview, all staff members with the first name provided by the anonymous caller were interviewed and all stated they had not had an inappropriate relationship with a resident. He stated Resident #7 later told his/her Peer Support Specialist (PSS) on the Lotus Program that one CNA made him/her feel uncomfortable when she came into his/her shower uninvited. He stated the facility found out staff member was CNA #24, and the Management Team viewed the text messages provided by the CNA and Resident #7 and determined their relationship was not a reportable event (even though the resident expressed the CNA made him/her feel uncomfortable, harassed, and uninvited in his/her space). Per the interview, the facility's process was that any allegation of abuse would be reported timely by the definition of the State Operations Manual (SOM). The VPO further stated staff should be able to report without fear of retaliation to ensure the safety of all the residents. Review of the facility's Freedom from Abuse and Neglect Policy, undated, revealed all residents were to be protected from harm. Continued review of the policy revealed types of abuse included: physical assault or abuse; hitting, slapping, pinching, and kicking. Further review revealed verbal abuse included: oral, written, and gestured language including, but not limited to, disparaging or derogatory terms directed to or within hearing distance of the resident. Review of the facility's Five (5) Day Follow Up Investigation revealed a statement from the DON stating she heard Resident #70 yelling in the dining room and when she went to check to see what was going on and Resident #70 stated Resident #3 told him/her to shut the hell up and stated nasty things. Continued review revealed Resident #70 was removed from the dining room. 2 a) Review of Resident #3's Admission Record revealed the facility admitted the resident on 05/10/2019 with diagnosis to include Anxiety Disorder, Bipolar Disorder, and Alcohol Dependency. Review of Resident #3's Quarterly MDS dated [DATE], revealed the facility had assessed the resident to have a BIMS score of ten (10) out of fifteen (15), i [TRUNCATED]

Based on interview, record review, review of the facility's policies, documents, Job Descriptions, and Plan of Correction (PoC) submitted for the 06/10/2023 and 09/13/2021 it was determined the facility failed to have an effective system to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the facility's Standard Recertification and Abbreviated Plan of Correction (POC) for the 06/11/2023 survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) failure to report allegations of abuse to State Agencies. During an Abbreviated/Partial Extended Survey initiated on 07/12/2023, the State Survey Agency (SSA) identified continued non-compliance in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) on 07/29/2023. The facility's Administration failed to report an allegation received on 07/20/2023 of sexual abuse of a resident by a Certified Nursing Assistant (CNA). The facility's Administration failed to facility's ensure its Quality Assurance Performance Improvement (QAPI) Committee reviewed, discussed, and tracked its past noncompliance regarding abuse. The facility's Administration additionally failed to ensure its QAPI Committee reviewed the current sexual abuse allegation reported on 07/20/2023, in order to determine the root cause of the abuse and implement person centered interventions to prevent further and/or future sexual abuse encounters of the affected resident or other residents. Interview and record review revealed the facility's Administration had no system in place to thoroughly investigate and determine the root cause of abuse allegations. In addition, the facility's Administration failed to ensure its QAPI program analyzed data collected to protect residents from abuse, and failed to ensure its QAPI program took effective measures to prevent and implement corrective actions for those residents affected by abuse. The facility's failure to have an effective system to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/20/2023 and was determined to exist on 07/20/2023 in the areas of of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F607, and F609). Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F-600 and F-609). The facility was notified of the Immediate Jeopardy on 07/29/2023 and is ongoing. In addition, Immediate Jeopardy (IJ) was also identified on 08/09/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867). The facility was notified of the Immediate Jeopardy on 08/09/2023 and is ongoing. Immediate Jeopardy (IJ) was also identified on 08/11/2023, and was determined to exist on 05/29/2023 in the area of 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 08/11/2023 and is ongoing. SQC was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, revised March 2022, revealed the Executive Director was ultimately responsible for the QAPI program, and for interpreting its results and findings to the Governing Body. Continued review revealed the responsibilities of the QAPI committee were to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services, identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process. Review further revealed the QAPI committee was to utilize root cause analysis to help identify where identified problems point to underlying systematic problems, and coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. Review of the facility's Executive Directors (ED) Position Description, undated, revealed the ED was responsible for the undertaking of corrective action, if applicable. Per review, the ED was also responsible for directing and performing quality assessment and assurance functions, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Review revealed the ED's responsibilities included: implementing programs to gather and analyze data for trends and to institute actions to resolve problems promptly; and reporting and making recommendations to appropriate committees. Review of the facility's Freedom from Abuse and Neglect Policy revealed all allegations involving staff necessitated suspension pending investigation. Continued review revealed allegations of abuse were to be reported immediately to the ED. Further policy review revealed the facility was to report all alleged violations and substantiated incidents to the State Agency and to all other agencies as required and was to take all necessary corrective actions depending on the results of the investigation. During an interview on 07/29/2023 at 3:35 PM with the the [NAME] President of Operations (VPO), he stated the process of any allegation of abuse was it should be reported timely by the definition of the State Operations Manual (SOM). He stated the Abuse Coordinator (ED) or designee was to report to all appropriate agencies immediately; however, he felt anyone could report abuse. The VPO stated any type of abuse could cause psychological harm to a resident resulting in fear, intimidation, embarrassment, and shame. He further stated therefore, abuse should be taken seriously and reported immediately, and staff should be able to report without fear of retaliation to ensure the safety of all the residents. During an interview on 08/09/2023 at 10:43 AM, with the Regional Human Resources (RHR) Business Partner, she stated she had been with the facility since January 2023, and her responsibilities included orientation, onboarding, connecting with operational leadership, being involved in employee investigations, compliance, and development of leadership. The RHR Business Partner stated she lead the facility's staff investigations, collecting statements, conducting interviews, making formal decisions and keeping leadership informed on what actions needed to be taken. She stated she was made aware the end of July 2023, about a possible allegation of a relationship with a staff member (CNA #24) involving a Resident (Resident #7). The RHR Business Partner stated when the allegation of sexual abuse was reported to the ED on 07/20/23, it should have been reported at that time based on facility policy, and CNA #24 should have been suspended immediately. She stated she was not aware the allegation had not been reported then, and felt the Corporate Operations (CO) should have made that call. According to the RHR Business Partner, she received a call on 07/24/2023, of another allegation involving the same resident (Resident #7) and same staff member (CNA #24) and both admitted to the allegation made on 07/20/2023. She stated from her investigation and being informed that even after the ED received the anonymous call of sexual abuse allegation on 07/20/2023, and CNA #24's contact with Resident #7 being validated the CNA continued to work at the facility, therefore, she was reporting her concerns to the VPO. In continued interview on 08/09/2023 at 10:43 AM, the RHR Business Partner stated the ED and DON had continued with plans to hire CNA #24 as a full-time employee and had already made her an offer of full-time employment, even after the allegation was reported. She stated through validated interviews with the facility's Human Resources (HR), the DON was pushing for hire of CNA #24 and planned to place her on a different unit and the ED had approved the CNA's hire, so she expedited a meeting with the Corporate VPO to discuss the need for immediate action. The RHR Business Partner stated at that time on 07/24/2023, she made all management aware to include the ED and DON that CNA #24 must be taken off the schedule and could not enter the facility and most definitely could not be hired, and she ensured the ED implemented this immediately. She stated the process the Corporate HR had in place was how they were able to prevent CNA #24 from further employment and ensured resident safety; however, she felt the situation could have been prevented if an appropriate DON had been in place in the facility at the time. The RHR Business Partner further stated an experienced DON would not have allowed the incident to have happened and would not have even considered doing things the way they occurred. Additionally, she stated she did not see any clinical oversight from the DON and ADON in the facility. During an interview on 07/29/2023 at 1:55 PM, with the ED, he stated he had been a Long-Term Care Director for fifteen (15) years, and worked as Interim ED at the facility since 06/14/2023. He stated he was responsible for the day-to-day functioning of the facility; and for ensuring the facility operated within the State and Federal Guidelines and maintained regulatory compliance regarding previously cited deficiencies. The ED stated he was the Quality Assurance (QA) Coordinator and was responsible for the QA program in the facility and for ensuring the ongoing audits related to previously cited deficiencies were completed. He stated any concerns of allegations, such as abuse should be identified, addressed and corrected immediately. The ED stated he was also the facility's Abuse Coordinator and had received education by the VPO on the facility's Abuse Policy which included physical, verbal, mental, misappropriation, sexual, exploitation, neglect, and seclusion when he started as the Interim ED. He stated it was his responsibility to report allegations, and he had two (2) hours to report to State Agencies and the Ombudsman. According to the ED, it was his and his staff's responsibility to protect residents first and foremost, and alleged staff should be escorted out of the building and suspended immediately pending the outcome of the investigation. He stated he expected himself and his staff to follow that process and to be able to report immediately and freely without fear of retaliation. In continued interview on 07/29/2023 at 1:55 PM, the ED stated the facility's investigation should be initiated by nursing as soon as they were informed, with statements obtained, interviews and education conducted. He stated the DON and Social Services Director (SSD) should immediately start resident and staff interviews, and skin assessments of noninterviewable residents. The ED stated he felt the SSD should be involved in that process because it was important for the resident to have another set of ears to listen to them to make sure nothing was being covered up. He stated he also felt it was important for the SSD to be involved to address potential psychosocial harm which might occur, as abuse of any type could manifest itself in a resident such as changed behavior, physical distress, upset stomach, anxiety, insomnia, stress, and affect their overall health. The ED stated in regards to the recent allegation of sexual abuse that involved Resident #7, the facility failed to decide whether the allegation of sexual involvement between a staff member and a resident met the criteria of sexual abuse. He stated however, he and the facility had since recognized that failure, and informed the State Survey Agency (SSA) Surveyor it had been sexual abuse, and the allegation should have been reported immediately, instead of trying to determine if it was actual or not. The ED stated we as management should have followed through on this issue for the safety of all the facility's residents. He further stated his expectation was that the facility followed its policies, so that every incident/allegation was consistent and thoroughly investigated, in order to determine the root cause through analysis to properly address concerns of residents and ensure their safety and protection, as well as to avoid repeated tags of deficient practice.

Based on interview, record review, review of the Administrator's Job Description, review of the Statement of Deficiencies (SoD) submitted for the 06/11/2023 and the Plan of Correction (POC) submitted for the 09/17/2021 survey and review of the facility's policy, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure they developed, implemented, and maintained an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. The facility was aware of potential allegations of abuse; however, failed to report to the State Survey Agency (SSA); conduct thorough investigations; develop and implement policies; monitor and audit identified non-compliance; and ensure the QAPI program comprehensively developed, implemented, and monitored its plan to ensure effectiveness in addressing repeat noncompliance and allegations of abuse to maintain substantial compliance. This was evidenced by review of the facility's deficient practice cited on an Extended Survey initiated on 06/10/2023 and concluded on 06/11/2023. Immediate Jeopardy (IJ) was identified on 06/10/2023 and was determined to exist on 04/22/2022 in the areas of 42 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689 all at a Scope and Severity (S/S) of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. Additional deficiencies were cited at 42 CFR 483.10 Resident Rights Exercise of Rights, F558 at a S/S of a D, and F584 at a S/S of an E; 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation F609 at a S/S of a D; 42 CFR 483.20 Resident Assessments F641 at a S/S of a D; 42 CFR 483.25 Quality of Care F686, F690, F691, F693, and F695, at a S/S of a D; 42 CFR 483.45 Pharmacy Services F761, at a S/S of a D; 42 CFR 483.60 Food and Nutrition Services F812 at a S/S of an E; and 42 483.80 Infection Prevention and Control F880 at a S/S of an D. Review of the facility's history revealed Immediate Jeopardy was identified on 09/17/2021, and was determined to exist on 04/17/2021, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at a S/S of J, and 42 CFR 483.25 Quality of Care, Pain Management (F697) at a S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600), and 42 CFR 483.25 Quality of Care, Pain Management (F697). The facility was notified of the Immediate Jeopardy on 09/13/2021. Continued review of the facility's history revealed on 06/29/2023, the SSA validated the facility removed the IJ, prior to exit on 06/29/2023, which lowered the S/S to a D at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (F656), and 42 CFR 483.25 Quality of Care, (F689), while the facility developed and implemented a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The facility's failure to have an effective system in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/20/2023 and was determined to exist on 07/20/2023 in the areas of of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F607, and F609). Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F-600 and F-609). The facility was notified of the Immediate Jeopardy on 07/29/2023 and is ongoing. In addition, Immediate Jeopardy (IJ) was also identified on 08/09/2023 and was determined to exist on 07/20/2023 in the areas of 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867). The facility was notified of the Immediate Jeopardy on 08/09/2023 and is ongoing. Immediate Jeopardy (IJ) was also identified on 08/11/2023, and was determined to exist on 05/29/2023 in the area of 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 08/11/2023 and is ongoing. SQC was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, revised March 2022, revealed the Executive Director (ED), whether a member of the QAPI Committee or not, was ultimately responsible for the QAPI program, and for interpreting its results and findings to the Governing Body. Continued review revealed the responsibilities of the QAPI Committee were to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes which support the delivery of care and services. Review revealed the QAPI Committee was also to identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process, utilize root cause analysis to help identify where identified problems point to underlying systematic problems, and coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. Further review of the policy revealed the QAPI Committee had the full authority to oversee the implementation of the QAPI program, including but not limited to, establishing performance and outcome indicators for quality of care and services delivered in the facility. Review of the facility's Executive Director's (ED) Position Description, undated, revealed the ED was responsible: directing and performing quality assessment and assurance (QAA) functions, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Continued review revealed the ED's responsibilities also included: the undertaking of corrective action, if applicable; implementing programs to gather and analyze data for trends and to institute actions to resolve problems promptly; and reporting and making recommendations to appropriate committees. Review of the Facility's Freedom from Abuse and Neglect Policy, undated, revealed all allegations involving staff was to necessitate suspension pending investigation. Per review of the policy, allegations of abuse was to be reported immediately to the ED. Further review revealed the facility was to report all alleged violations and substantiated incidents to the State Agency and to all other agencies as required and was to take all necessary corrective actions depending on the results of the investigation. Review of the Plan of Correction (POC), for the survey dated 09/17/2021, revealed for the Immediate Jeopardy identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 the facility educated staff and the DON and/or the ED were to report the audit results weekly to the QAPI Committee for four (4) weeks. Continued review of the 09/17/2021, POC revealed Immediate Jeopardy was also identified at 42 483.21 Comprehensive Resident Centered Care Plan, F656 which revealed the facility's ED, DON, and/or SSD were to submit results of the audit findings weekly times six (6) months to the QAPI Committee until the issue was resolved. The ED, DON, and SSD received education regarding care plans and the discharge process to include resident change in condition, discharge without proper medical authority and care plan revision, with a posttest. Review of the Statement of Deficiencies (SoD) for the Recertification Survey dated 06/11/2023, revealed 42 483.21 Comprehensive Resident Centered Care Plan, F656 was cited at Immediate Jeopardy again. In addition, 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F609 was cited at Immediate Jeopardy. During the Abbreviated Survey on 08/11/2023, 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 and F609 were cited at Immediate Jeopardy. In addition, 42 483.21 Comprehensive Resident Centered Care Plan, F656 was also cited at Immediate Jeopardy. Review of the facility's monthly QAPI Committee meeting minutes, from 10/25/2022 through 07/28/2023, revealed the Committee members noted as present, but not limited to, were the Medical Director via phone; Assistant Director of Nursing (ADON); Minimum Data Set (MDS); MDS Coordinator; Activities Director (AD); Business Office Manager (BOM), DON; Advanced Practice Registered Nurse (APRN); Unit Managers (UM); Social Services Director (SSD); Staff Development Coordinator (SDC); and Maintenance Director. Continued review of the QAPI meeting minutes for the dates of 10/25/2022, 06/20/2023, 06/23/2023, 06/28/2023, 06/30/2023, 07/07/2023, 07/14/2023, 07/21/2023, 07/24/2023, 07/27/2023, and 07/28/2023, revealed no documented evidence the minutes included discussion of any type of resident abuse and neglect, and/or to include the 07/20/2023, the allegation of sexual abuse involving perpetrator, CNA #24 towards Resident #7. During an interview with Licensed Practical Nurse/Infection Preventionist/Assistant Director of Nursing (LPN/IP/ADON) on 08/09/2023 at 2:13 PM, she stated she started working at the facility in September 2021, and reported to the DON, ED, and the Regional Clinical Nurse (RCN) and/or Regional Compliance Officer (RCO). The LPN/IP/ADON stated she assisted with QAPI through gathering information for audits from a nursing standpoint, and through any additional concerns that needed to be addressed in the QAPI meetings. She stated she was informed that QAPI was planned to go over incidents; self-identified issues; and the team was to come up with a plan, review it, and review some more until QAPI determined whether the goals had been met. The LPN/IP/ADON stated QAPI met once a month routinely; however, had met more frequently the last couple months related to the increase in facility reportable allegations which included abuse. The LPN/IP/ADON was unable to provide any information confirming QAPI had met and/or discussed the 07/20/2023, Resident #7 allegation of staff (CNA #24) sexual abuse. During an interview with the DON on 08/09/23 at 4:00 PM, she stated she reported to the ED and RCN. The DON stated she had been working at the facility for two (2) years and in the DON position since 05/15/2023. She stated she was responsible to ensure clinical processes were being followed, and monitoring and ensuring compliance and staff performance. The DON stated her responsibilities also included to ensure regulations were being followed per staff documentation review; holding/attending clinical meetings; reviewing resident laboratory work (labs); reviewing incident reports, and attending QAPI meetings at least monthly, or sooner if something arose. The DON stated the facility had been instituting QAPI meetings daily and weekly for the last month related to incidents. She stated the purpose of QAPI was to identify areas of improvement; set a plan; follow it; track it with department heads; and ensure the facility's systems did not fail. She stated the importance of a system-wide approach was to ensure resident safety and improve the investigation process. The DON further stated the deficient practice and failure related to the allegation of sexual abuse involving a staff member and a resident occurred because the facility failed to follow through with the investigation process, utilize the abuse policy, and implement the staff code of ethics. During an interview on 08/09/2023 at 4:31 PM, with the ED, he stated he had been the Interim ED since 07/14/2023. He stated he reported to the Regional [NAME] President of Operations (RVPO), and his responsibilities included to run the daily operations and oversight of the facility and staff. The ED stated his responsibilities also included continued communication with staff through morning meetings to discuss issues/incidents in different departments, staffing, supplies and equipment that was needed, any admissions, or discharges, and to give opportunity for each department to communicate with the whole Interdisciplinary Team IDT. He stated the IDT included the DON, ADON, SDC, UM's, MDS, AD, SSD, BOM, Dietary Manager (DM), Admissions Director, Maintenance Director, and Human Resources Director. The ED stated he was also to report to the Governing Body (GB); however, he was not sure who all that involved, other than the VPCO and the facility board representatives. He stated they would supply him with plenty of resources to operate the facility efficiently and effectively. According to the ED, he and the VPCO had routine conference calls, emails, text messages and routine in-person meetings to discuss issues and collaborate to best address the concerns; and the VPCO advised and offered services to obtain necessary resources. In continued interview on 08/09/2023 at 4:31 PM, the ED stated the facility's QAPI should identify and address all and any resident issues, to include involvement of the Medical Director, and the IDT to discuss areas that needed to be improved and/or what the facility could implement to ensure residents achieved the highest practicable mental, physical, and social well-being. He stated the QAPI met frequently and sometimes daily to discuss issues; to look at tracking and trending; conduct audits; and ensure education of staff. The ED stated QAPI met; however, failed to discuss the incident on 07/20/2023, related to a staff member having an inappropriate relationship with Resident #7. The ED stated the facility needed to recognized the importance to do a more thorough root cause analysis and get to the root of the problem with more emphasis on QAPI discussion and involvement. He stated the QAPI process failed due to a difference of opinion, and by not performing a thorough investigation. The ED stated the facility failed in deciding whether the allegation of sexual involvement between a staff member and a resident met the criteria of abuse; however, he and the facility had since recognized their failure. The ED informed the State Survey Agency (SSA) Surveyor, the incident involving the perpetrator, Certified Nursing Assistant (CNA) #24 and Resident #7 had been abuse and the allegation should have been reported immediately. He stated instead of the facility trying to determine if it was actual abuse or not, we as management should have followed through for the safety of all residents. The ED stated his expectation was that the facility followed its policies, so that every incident/allegation would be consistent and thorough, in order to perform the root cause analysis to properly address the concerns of residents and ensure they were safe and protected, as well as to properly avoid repeated deficient practice tags.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, ensuring staff reported without fear of retaliation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken, to protect the residents from abuse for one (1) of thirty-nine (39) sampled residents, Resident #7. Review of the facility's Alleged Abuse Incident Nursing Description Note, dated 07/20/2023, revealed an anonymous call was received by the Executive Director (ED) during which the caller reported a relationship involving texting and sending inappropriate pictures via text messages to a resident (Resident #7) by a facility staff Certified Nurse Aide (CNA #24). Interview with Resident #7 and with facility staff revealed they were afraid to report allegations of abuse, out of fear of retaliation. Therefore, the allegation of sexual abuse was not reported timely. Review of the Quality Assurance (QA) Meeting Sign-In Sheet dated 07/20/2023, revealed the QA Committee met to discuss the Investigation Process to include reportable events, resident information needed, and the process of investigating. However, review of the facility's documentation revealed no documented evidence to support the facility thoroughly investigated the allegations reported on 07/20/2023, by the anonymous caller, and implemented corrective actions. The facility's failure to ensure its policies were implemented related to abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/29/2023 at 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), at the highest Scope and Severity (S/S) of a K; 483.12 Freedom from Abuse, Neglect, and Exploitation (F607 & F609), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12, Free from Abuse, Neglect, and Exploitation (F600). The Immediate Jeopardy was determined to exist on 07/20/2023. The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is ongoing. The findings include: Review of the facility's, Compliance and Ethics - Communication Policy dated December 2020, revealed the Compliance and Ethics Committee was responsible for establishing, implementing and overseeing the methods by which information associated with the Compliance and Ethics Program was communicated. Continued review revealed employees were encouraged to report suspected civil, criminal or administrative violations to the Compliance and Ethics Committee and were protected from retaliation and retribution. Review of the facility's, Freedom from Abuse and Neglect Policy, undated, revealed all residents were to be protected from harm. Review revealed the Executive Director (ED) was responsible for oversight of abuse prohibition standards, and all allegations involving staff necessitated suspension pending investigation. Per facility policy, the definition of abuse was the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the policy revealed types of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Continued review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Review revealed types of abuse might include: mental abuse; humiliation, harassment, threats; taking unauthorized resident photos or video recordings; posting of any resident photos, video recordings or other resident information on social media networks. Review revealed additional types of abuse included sexual harassment, sexual coercion, and verbal abuse. Further review revealed training included procedures for reporting incidents of abuse, and assurance that any individual who made a report or was in the process of making a report was not retaliated against. Review further revealed the training was to include prohibition of staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate a resident(s) such as any type of equipment (ex. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media. Further review of the policy; however, revealed the facility had not addressed the coordination of QAPI to identify, monitor, or implement corrective actions related to allegations of abuse. Review of Resident #7's Admission Record revealed the facility admitted the resident on 05/29/2023, with diagnoses including Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed on 07/20/2023 the ED received an anonymous call that Resident #7 was involved in a relationship with a staff member,with only first name given. Continued review revealed the caller was unable to give a last name or description of the employee. Per review, the caller stated the employee and resident had been texting and sending inappropriate pictures via text messages. Review revealed Resident #7 was interviewed at that time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. Review of the note revealed the Human Services Director (HSD) and Director of Nursing (DON) interviewed all employees with the first name provided and all denied any inappropriate relationship with a resident or sending inappropriate pictures to a resident. Review of the Facility Resident Description section review revealed on 07/20/2023, Resident #7 was interviewed and gave a signed statement noting he/she had never received any pictures from any staff members and he/she felt completely safe at the facility. Continued review revealed on 07/26/2023 Resident #7 spoke with a Peer Support Specialist (PSS) and stated that he/she had not been honest when first interviewed. Per review, Resident #7 told the PSS he/she had had a friendship with CNA #24, an agency CNA, and attempted to cut the relationship off. Further review revealed Resident #7 reported CNA #24 would come to his/her room and shower room which made him/her feel uncomfortable. Review further revealed Resident #7 stated he/she realized he/she was in a vulnerable state due to his/her sobriety, but thought he/she could handle the situation on his/her own. Additional review of the facility's Alleged Abuse Investigation of the Immediate Action Taken Description section dated 07/26/2023 at 6:26 PM, revealed CNA #24 was removed from the schedule and the CNA's agency was notified of the allegations and that the CNA would no longer be able to work at the facility. Continued review revealed on 07/26/2023, Resident #7 received a psychiatric (psych) telehealth visit to ensure the resident was not having any psychosocial distress. Review further revealed Resident #7's care plan was reviewed and updated, and an intervention added to monitor for signs and symptoms (s/s) of psychosocial distress. In addition, review revealed the Medical Director and Police were notified and a full investigation was initiated. Review of agency CNA #24's Clock In and Out Sheet revealed she worked on Saturday 07/22/2023 from 7:00 AM to 7:00 PM and on Sunday 07/23/2023 from 7:00 AM to 11:00 PM (After the ED received the anonymous caller's report on 07/20/2023). Observation revealed the facility had one (1) small five (5) by seven (7) framed posting hanging on the wall in the middle of the hall on the [NAME] Hall noting staff would be free from retaliation when reporting abuse. Interviews with staff revealed they were not aware of the posting displayed on the [NAME] Hall wall and had not observed any such posting throughout the facility. Observation on 07/27/2023 at 9:00 AM, revealed Resident #7 lying on his/her bed, awake, dressed and well-groomed. In interview, at the time of observation, Resident #7 stated at first, he and CNA #24 were just talking a lot and their relationship was as friends, because it was nice having someone close to talk to as he/she did not have any family or friends. Resident #7 stated CNA#24 then started sending him/her nude photos of herself on snapchat on his/her phone, and the relationship progressed and the CNA kissed him/her which made him/her uncomfortable. The resident stated he/she told CNA#24 he/she did not feel comfortable having that kind of relationship because of being in treatment for his/her addiction. Resident #7 stated he/she told CNA #24 he/she needed to continue to work his/her program to recovery before having an intimate relationship with anyone. According to Resident #7, CNA#24 continued to send nude photos however, even after being told to stop. The resident stated CNA #24 would wake him/her up at all hours of the night coming into his/her room when she was working at the facility. Resident #7 stated he/she confided in two (2) other residents on the Lotus Unit about his/her concerns with CNA #24, and those residents asked to see the photos, so he/she showed them the photos. Resident #7 stated he/she told the two (2) other residents he/she told CNA#24 to stop, and it was making him/her uncomfortable because she kept coming into his/her room at night and entering the bathroom when he/she was showering. The resident stated CNA #24 entered the shower multiple times when he/she was showering even though he/she kept telling her to stay out of the shower room. In continued interview on 07/27/2023 at 9:00 AM, Resident #7 stated a rumor had gotten out all over the facility about what was going on. The resident stated the DON and the Human Resources (HR) person called him/her into their offices to talk about the incidents. Resident #7 stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA# 24 in trouble. The resident stated, I was afraid if I told the truth about the texting and the photos, they would move me out of the facility, and I really like it here and I want to finish out my program. Resident #7 stated the photos of CNA #24 topless and showing her bare breasts were sent through a social media app called Snapchat, and the photos deleted after twenty-four (24) hours. The resident stated he/she was now feeling harassed by CNA#24 because of her continuing to come to his/her room late at night and by her entering the shower room when he/she was unclothed and showering. Resident #7 stated CNA #24 entered his/her room the other night on the 7:00 PM to 7:00 AM shift when she was not assigned to work on his/her unit, the Lotus Unit. According to Resident #7, on 07/27/2023 at 9:00 AM, Licensed Practical Nurse (LPN) #1 saw CNA #24 coming in and out of his/her room, and asked the CNA why she was on the Lotus Unit when she was supposed to be working another unit. Resident #7 stated after that incident, LPN #1 and LPN #11 came in and talked with him/her about why CNA#24 was in his/her room, and he/she told them CNA#24 would not leave him/her alone. The resident stated he/she told the LPN's about the shower incidents and that he/she was feeling harassed, shamed, and embarrassed by CNA #24, and by the managers at the facility who kept asking him/her about the relationship. Resident #7 further stated he/she felt bad about saying anything to anyone because he/she did not want to get CNA#24 in trouble or cause her to get fired; however, he/she just wanted her to leave him/her alone. During a phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated she had been working on the Lotus Unit since February 2023. LPN#1 stated prior to working at the facility she had worked for fifteen (15) years at the jail and had a lot of experience working with substance abuse clients. She stated on 07/24/2023, she heard staff members talking on the unit about something going on between CNA #24 and Resident #7. LPN #1 stated LPN #11 agreed what she had heard should be reported and made a call to the DON that night to report CNA #24 and Resident #7 being in a relationship. She stated after they (the LPNs) heard about the relationship, they went to talk with Resident #7. According to LPN #11, they were talking to Resident #7 and the resident told them he/she decided to cut it off with CNA #24; however, she started harassing him/her and invading his/her space. She stated she had Resident #7 sign a statement which she handed to the Assistant Director of Nursing (ADON) at the end of her shift that morning. Continued phone interview on 07/27/2023 at 8:00 PM, with LPN #1 revealed she stated two (2) other residents, Resident #9 and Resident #13, told her CNA #24 had been harassing Resident #7 and told her there were pictures exchanged by phone of CNA #24. LPN #1 stated Resident #7 said he/she ended the relationship because he/she needed to work on his/her sobriety, and CNA #24 had not accepted it well. She stated Resident #7 told her he/she was embarrassed and uncomfortable talking about the relationship with CNA #24. LPN #1 stated she saw CNA #24 enter Resident #7's room and was on the Lotus Unit in the middle of the night when she was not assigned to work on the unit. The LPN stated the DON knew about all of this, but the DON did not interview Resident #7 because she told the ADON to do it. She stated she reported everything to the Unit Manager/Infection Prevention (UM/IP) Nurse #1 and Registered Nurse (RN) #2 who both defended CNA #24 and stated Resident # 7 was manipulating and taking advantage of the CNA. The LPN further stated they made Resident #7 the perpetrator in the situation and revised his/her care plan to make him/her care in pairs and care planned him/her for seeking relationships with staff. During an interview, on 07/27/2023 at 8:50 PM, with RN #3 she stated she primarily worked the Lotus Unit and had been at the facility almost two (2) years. RN #3 stated there was an inappropriate physical relationship between CNA #24 and Resident #7. She stated CNA #24 had been pursuing Resident #7 and always going to his/her unit and into his/her room. The RN stated CNA #24 would constantly be wherever Resident #7 was and was always in his/her space. She stated Resident #9 reported CNA #24 had sent Resident #7 naked photos, which he/she had seen and had also seen the text messages from the CNA. RN #3 stated she heard about the inappropriate relationship about two (2) weeks ago and told the DON, who said she would take care of it. She stated she could not see where anything happened after she reported the incident to the DON. RN #3 stated after she reported the inappropriate relationship to the DON she started receiving a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot a papers to redo and said she was not doing her job. In a continued interview, on 07/27/2023 at 8:50 PM, the RN #3 stated after a week went by she then heard about the photos; however, after the backlash, she stated she was too scared to say anything to the DON about the photos. She stated she told her brother about the relationship between CNA #24 and Resident #7 and he reported it anonymously to the ED. RN #3 stated she again noticed nothing was done about the inappropriate relationship so she decided to make an anonymous call herself to the State to report it. She stated there were rumors all over the facility about what was going on with Resident #7 and CNA #24 and none of the staff were doing anything about it. She stated Resident #7 was telling everyone CNA #24 was calling and texting his/her phone and harassing him/her and he/she just wished it would stop. RN #3 stated after it came out about the photos, Resident #7 was telling other residents and staff the facility's management team were badgering him/her and harassing him/her about it. During interview CNA #24 stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency staff for about two (2) months. CNA #24 stated she had worked all the units including the Lotus Unit. She stated she had been last educated on the facility's Abuse Policy a couple of weeks ago by the Staff Development Coordinator (SDC). The CNA stated the different types of abuse, and said sexual abuse would be touching inappropriately, making someone feel uncomfortable, and that walking in the shower would not be considered sexual unless it was intentional. She stated she had been texting with Resident #7 and the resident would text her about how he/she was feeling or if he/she wanted her to buy him/her something. CNA #24 stated she sent Resident #7 pictures of herself and her kids, family type pictures; however, now that she had researched it, she realized maybe she should not have done that. She stated she also sent Resident #7 pictures of herself fully clothed so the resident could show his/her aunt what she looked like. The CNA stated she wished she had known that her friendship with Resident #7 was not appropriate. CNA #24 stated there had never been any kissing or nude photos involved. She stated she was told Resident #7 reported he/she was being taken advantage of by her and he/she was vulnerable. The CNA stated they told her Resident #7 said she walked in on him/her in the shower, and she acknowledged she had walked in on the resident in the shower by accident before. She further stated, knowing what she knew now, she would never have let Resident #7 have her phone number, would never have sent him/her photos, and would never have sent text messages to him/her. During an interview with LPN #11, on 07/28/2023 at 4:00 PM, she stated she worked as the night shift supervisor on the 11:00 PM to 7:00 AM shift and had been employed by the facility for three (3) years. She stated she had been trained on abuse by the DON and ADON almost daily for the last several weeks, and verbalized the different types of abuse, including sexual. She stated if an allegation of abuse occurred, staff were to immediately contact the ED who would then contact the DON, who was supposed to start an investigation and suspend the worker during the investigation. LPN #11 stated she overheard staff talking about an aide (CNA #24) on the Lotus Unit who was going into Resident #7's room when the aide was not assigned to work that unit, and was calling the resident on phone. She stated she also heard the aide looked Resident #7 up on Facebook and started having an inappropriate relationship with the resident that involved sending sexual pictures to him/her. The LPN stated when she heard about the relationship, she contacted the DON who said they already knew about it the week before and the ED was already investigating it. She stated she wrote a signed statement on 07/25/2023 at 12:14 AM, and gave it to the DON at the end of her shift In continued interview with LPN #11, on 07/28/2023 at 4:00 PM, she stated the week before the DON and ED moved CNA #24 to another unit to prevent her from having contact with Resident #7. The LPN stated however, on night shift on 07/23/2023, CNA #24 was assigned to work another unit, but she kept seeing the CNA coming in and out of Resident #7's room when she was not supposed to be on the unit. The LPN stated LPN #1 asked CNA #24 if she had been reassigned to work the Lotus Unit that night and CNA #24 stated no and left the unit. She stated she and LPN #1 then went to talk with Resident #7 about the relationship between him/her and CNA #24, but the resident stated there was no relationship between them. LPN #11 stated LPN #1 had a better rapport with Resident #7, and asked LPN #11 to leave the room so she could talk to Resident #7. She stated a few minutes later, LPN #1 called her back into Resident #7's room and the resident told her he/she had something going on with CNA #24; however, did not want the relationship anymore because he/she was trying to get clean. The LPN stated Resident #7 told her CNA #24 kept bothering him/her and kept coming into his/her room. LPN #11 further stated Resident #7 told her he/she just wanted CNA #24 to leave him/her alone. During an interview with the ED, on 07/29/2023 at 1:55 PM, he stated he had been a Long Term Care (LTC) Director for fifteen (15) years and had been working as the facility's Interim ED since 06/14/2023. He stated he had been educated on the facility's Abuse Policy by the [NAME] President of Operations (VPO) when he took over as the Interim ED in June. The ED stated staff were to immediately report any signs of abuse to their supervisor or call him since he was the Abuse Coordinator. The ED stated abuse was to be reported in two (2) hours, and the report was to be sent to the State Agency (SA), Adult Protective Services (APS), and the Ombudsman. He stated all staff were responsible for protecting residents from abuse. The ED stated if a staff member was the reported perpetrator in an allegation, the staff member should be escorted out of the facility and suspended immediately pending the outcome of the investigation. He stated an investigation should be started immediately into any and all allegations of abuse and was to be initiated by the DON or ADON. The ED stated written statements and interviews were to be obtained quickly and the Social Worker (SW) was to be involved immediately because it was important for the resident to have another set of ears to listen to them and make sure nothing was being covered up. He stated the SW was to conduct a psychosocial assessment of the resident to determine if the resident had experienced harm, such as potential psychosocial harm. In continued interview with the ED, on 07/29/2023 at 1:55 PM, he stated on 07/20/2023 he received an anonymous call saying nude pictures had been sent to a resident (Resident #7) by somebody identified by first name only, no last name given. He stated after he received the call, he tried to figure out who the staff member was, and notified the Human Resource (HR) department who tried to find out who all the staff members with the identified first name were working. The ED stated he interviewed Resident #7 and the resident denied anything had occurred and he/she stated he/she had not been abused. The ED stated after discussing the incident with the Corporate [NAME] President of Operations (VPO), they decided the incident was not reportable because everyone denied there being a relationship or that abuse had occurred on 07/20/2023. He stated the facility had not sent in a reportable on 07/20/2023, because after hearing the relationship between Resident #7 and CNA #24 was consensual, and since the resident had a BIMS of fourteen (14) and denied any abuse, feeling stressed, or coerced, they felt it had not rose to the level of being reportable. The ED stated on 07/24/2023, a second allegation came in involving the same individuals, and he and the DON questioned Resident #7 again; however, the resident again told them he/she was fine and did not feel abused. The ED stated he again called HR to discuss what should be done about the second allegation. He stated he was told the allegation was not abuse and not reportable because the resident denied it happened. In further interview on 07/29/2023 at 1:55 PM, the ED stated on 07/26/2023, Resident #7 confided in his/her Peer Support Specialist (PSS) in the Lotus Program and a lot more information came out then. The ED stated the Interdisciplinary Team (IDT) met as a QA team on 07/26/2023, and that was when it was determined an investigation should be cited. He stated on 07/26/2023, it was determined the facility should have reported the incidents that occurred on 07/20/2023 and 07/24/2023 immediately to the State Agency as abuse and investigations should have been started. The ED stated he was not aware CNA #24 had been told to stay off the Lotus Unit where Resident #7 resided, and was not aware she worked two (2) more shifts at the facility after the 07/20/2023 allegations were made. He stated, in thinking about the 07/20/2023 incident, obviously the facility should have made a very different decision regarding the allegation, and it should have been reported because a caregiver in any role allegedly sending nude pictures to a resident was considered abuse. The ED stated he expected all facility staff to follow the abuse process and policy and expected them to report abuse without fear of retaliation. Additionally, he stated he felt the IDT had met substantially and had a QAPI meeting to discuss other concerns but had not specifically discussed the incidents involving Resident #7 and CNA #24. During an interview with the DON on 07/29/2023 at 2:47 PM, she stated she had been the DON at the facility since May 2023, and had been educated on abuse by the SDC multiple times since then. The DON stated sending pictures was not inappropriate if the individuals were involved in a consensual relationship. She stated on 07/20/2023, the ED told her he received an anonymous call who said an employee only known has first name only had been sending inappropriate pictures to Resident #7. She stated she did not report the allegation to the State Agency (SA), Adult Protective Services (APS), or the Ombudsman because the ED already knew about it. The DON stated the facility started an investigation immediately by contacting HRD because they did not know who the staff member was since the caller only identified her by first name. She stated she, the HRD, and ED interviewed Resident #7 and the resident denied everything and said he/she had not been abused. The DON stated she and the HRD started interviewing all the staff members that had the identified first name that was provided by the anonymous caller. Per the interview, CNA #24 was interviewed; however, denied calling, texting, or sending any pictures to Resident #7. She stated she did not know why the facility should have reported the allegation because Resident #7 denied the relationship occurred and the resident had a BIMS score of fourteen (14), and had the right to a consensual relationship. In continued interview with the DON, on 07/29/2023 at 2:47 PM, she stated on 07/26/2023, the PSS for the Lotus Program came to the ED and told him Resident #7 had not been honest in his/her interviews and admitted to being involved in a friendship with CNA #24. The DON stated Resident #7 told the PSS the CNA had walked in the shower room a few times when he/she was unclothed and showering, and gave the name of who the CNA was (CNA #24). She stated after receiving the information from the PSS, we started resident interviews, skin assessments, and called CNA #24. The DON stated she felt the facility had conducted a thorough investigation because they had interviewed Resident #7 and interviewed every staff member with the first name only and all those interviewed denied everything. She stated she guessed however, the relationship between CNA #24 and Resident #7 should have been reported on 07/20/2023, when the initial call came in because it was an allegation of abuse. In further interview on 07/29/2023 at 2:47 PM, the DON stated on 07/26/2023, LPN #11, the nighttime supervisor, called her after midnight and told her an aide had been at the desk and said a staff member identified by first name only, was in a relationship with a resident, Resident #9, but at the time she thought all the staff were just gossiping. The DON stated she asked LPN #11 to call the ED and go interview Resident #9. She stated she was on the phone when LPN #11 interviewed Resident #9 and the resident just laughed and said he/she was not involved with a staff member. The DON stated Resident #9 wrote a statement and signed it, and said he/she did not know what they were talking about. According to the DON, LPN #11 called her back later and said the staff member got the resident's name wrong and it was actually Resident #7. Further, on 07/29/2023 at 2:47 PM, the DON stated she told LPN #11 it sounded like staff were just gossiping and got the information wrong because she and the ED had already investigated that allegation. The DON stated LPN #1 later talked to Resident #7, and he/she admitted to the LPN he/she had been involved in a friendship with CNA #24. She stated at that point, she and the ED went and interviewed Resident #7 again and he/she admitted he/she and CNA #24 were just friends. The DON stated on 07/27/2023, Resident #7 then told the PSS in the Lotus Program what had happened between him/her and CNA#24. She stated she did not think Resident #7 was a victim, and felt the resident manipulated CNA #24 and since they were both adults they had the right to a consensual relationship. The DON stated all staff were to report abuse immediately so an investigation could be initiated, and the two (2) hour reporting time frame meant the facility had two (2) hours to investigate an abuse allegation before reporting it to the State Agency (SA), APS, and the Ombudsman. She stated all staff and residents should be able to report allegations of abuse without fear of retaliation. She further stated the QA team was meeting almost daily to discuss abuse; however, had not discussed the 07/20/2023 incident, as they had determined the allegation was not abuse. During an interview with the VPO, on 07/29/2023 at 3:35 PM, he stated an anonymous call was received on 07/20/2023, regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS score of fourteen (14) which indicated the resident was of sound mind, and he/she had the right to have a relationship of his/her own choosing. The VPO stated Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. According to the VPO, all staff members with the first name provided by the anonymous caller were interviewed, and they all said they had not had an inappropriate relationship with a resident. She stated Resident #7 later told his/her counselor in the Lotus Program that a CNA made him/her uncomfortable when she came in when he/she was showering. The VPO stated we found out it was CNA #24, and the management team viewed the text messages in which Resident #7 stated over and over that he/she wanted a relationship with the CNA. He stated based on the text messages the incident was not a reportable event. The VPO stated the facility's process was for any allegation of abuse to be reported timely by the definition of the State Operations Manual (SOM), which would be within two (2) hours. He stated the Abuse Coordinator or designee should report abuse immediately; however, anyone could report an abuse allegation. In addition, the VPO further stated staff should be able to report without fear of retaliation to ensure the safety of all residents. During an interview on 08/09/23 at 10:43 AM, the Regional Human Resource Business Partner (RHSBP) stated her responsibilities included being involved in assisting with investigations, compliance, and development of leadership. She stated she was made aware the end of July, by the ED and DON, of an inappropriate relationship involving Resident #7 and CNA #24. The RHSBP stated the ED said he had gotten a call, on 07/20/2023, about a possible allegation of a relationship with a staff member involving nude pictures and a resident and did not know what do. She stated she did not know the protocol; however, told them the allegation might be a reportable incident and informed the ED and DON they should do whatever needed to be done on that side of things. The RHSBP stated she told them they needed to launch an investigation and the ED said how, I have vague information. She stated she told the ED, you have a first name, so have the DON pull a roster of al [TRUNCATED]

Based on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure allegations of sexual and physical abuse were reported to State Agencies and local law authorities immediately, but no later than two (2) hours after the allegations were made for two (2) of thirty-nine (39) sampled residents ( Residents #7 and #1). 1. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. Review of the facility's documentation; however, revealed the facility failed to notify/report the allegations of potential abuse to the state agencies and law enforcement, to protect its resident, even though staff had been trained on abuse to include reporting requirements. 2. On 12/10/2022 Resident #1 ran into the hallway yelling help me, she is hitting me. However, LPN #11 failed to report the allegation as abuse. The facility's failure to ensure allegations of sexual and physical abuse were reported to State Agencies and local law authorities immediately has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/29/2023 at 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), at the highest Scope and Severity (S/S) of a K; 483.12 Freedom from Abuse, Neglect, and Exploitation (F607 & F609), at the highest S/S of a J; Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, Free from Abuse, Neglect, and Exploitation (F600). The Immediate Jeopardy was determined to exist on 07/20/2023. The facility was notified of the Immediate Jeopardy on 07/29/2023. IJ is ongoing. The findings include: Review of the facility's, Compliance and Ethics - Communication Policy dated December 2020, revealed the Compliance and Ethics Committee was responsible for establishing, implementing and overseeing the methods by which information associated with the Compliance and Ethics Program were communicated. Continued review revealed employees were encouraged to report suspected civil, criminal or administrative violations to the Compliance and Ethics Committee and were protected from retaliation and retribution. Review revealed internal and external reporting systems had been established and could be accessed anonymously. Per policy review, reporting systems included: an internal tollfree reporting hotline; a landing page on the company's intranet with information and tools for reporting; the name and address for sending written reports to the Compliance Officer; names and contact information of the State Survey Agency, and Ombudsman program. Further review revealed all pertinent information regarding how and where to report were prominently posted in a notice approved by the Compliance and Ethics Committee; and all reports of suspected violations were reviewed by the Compliance and Ethics Committee. In addition, review revealed investigations were conducted as necessary to address any allegations that were deemed credible. Review of the facility's, Freedom from Abuse and Neglect Policy, undated, revealed all residents would be protected from harm, and all allegations involving staff was to necessitate suspension pending investigation. Per facility policy, the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Continued review revealed staff members were to identify and assess suspected or alleged reports of abuse and neglect. Review of the facility's, Abuse Prevention Program Policy revised December 2016, revealed in the Policy Statement, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Continued review revealed as part of the resident abuse prevention, the administration was to protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 1. Review of Resident #7's Admission Record revealed the facility admitted the resident on 05/29/2023 with diagnoses to include Osteomyelitis, Anxiety, Opioid Abuse, and other Stimulant Abuse. Review of Resident #7's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, entered by the Director of Nursing (DON), revealed the Executive Director (ED) received an anonymous call on 07/20/2023, stating Resident #7 was involved in a relationship with a staff member known by first name only. Per review, the caller was unable to give a description of or last name of the employee. Continued review revealed the caller stated the employee and resident had been texting and sending inappropriate pictures via text messages. Review revealed Resident #7 was interviewed at the time and denied any inappropriate relationship with a staff member or receiving any inappropriate pictures via text messages. Review further revealed the Human Services Director (HSD) and DON interviewed all employees with the first name identified by the anonymous caller, and all denied any inappropriate relationship with a resident or sending inappropriate pictures. Review of the Alleged Abuse Investigation Nursing Incident Description note, Facility Resident Description section review revealed Resident #7 was interview on 07/20/2023. Further review of the Alleged Abuse Investigation Nursing Incident Description note dated 07/26/2023 at 6:26 PM, revealed Resident #7 spoke with the Peer Support Specialist (PSS) and stated he/she had not been honest when first interviewed. Review revealed Resident #7 told the PSS he/she did have a friendship with Agency CNA #24, and attempted to cut the relationship off; however, the CNA came to his/her room and in the shower room which made him/her feel uncomfortable. Per review, Resident #7 stated he/she realized now he/she was in a vulnerable state due to his/her sobriety and thought he/she could handle the situation on his/her own. Review of the Facility Resident Description section review revealed on 07/26/2023 Resident #7 told the PSS CNA #24 kept coming to his/her room and coming in the shower room when he/she did not require assistance. Continued review of the Facility Resident Description revealed Resident #7 stated CNA #24 never physically touched him/her; however, she just made him/her feel uncomfortable. In addition, review of the facility's Alleged Abuse Investigation Immediate Action Taken Description section dated 07/26/2023 at 6:26 PM, revealed CNA #24 was removed from the schedule and the CNA's agency notified of the allegations and that the employee would no longer be able to pick up shifts at the facility. Further review revealed on 07/26/2023 Resident #7 received a psychiatric (psych) telehealth visit to ensure he/she was not having any psychosocial distress and his/her Care plan was review and updated with an intervention to monitor for signs and symptoms (s/s) of psychosocial distress. Observation on 07/27/2023 at 9:00 AM, revealed Resident #7 fully and appropriately dressed lying on his/her bed awake. In an interview at the time of observation Resident #7 stated CNA #24 sent him nude photos of herself on his/her phone using Snapchat (a social media app). Resident #7 stated at first their relationship was consensual and as friends because it was nice to have someone to talk to as he/she had no family or friends. The resident stated the relationship progressed and CNA #24 kissed him/her which made the resident uncomfortable. Resident #7 stated he/she told CNA #24 he/she did not feel comfortable having that kind of relationship because of being in treatment for his/her addiction, and he/she needed to continue to work the program to recovery before having an intimate relationship with anyone. The resident stated however, CNA #24 continued to send nude photos of herself after being told to stop and woke him/her at all hours of the night coming into his/her room when she worked her shifts at the facility. Resident #7 stated he confided in two (2) other residents on his/her unit regarding his/her concerns and the other residents asked to see the photos. The resident stated he/she showed the other residents the photos, and told them he/she told CNA #24 to stop because it was making him/her uncomfortable because she was coming into his/her room at night and entering the bathroom when he/she was showering. Resident #7 stated CNA #24 entered the shower room multiple times when he/she was in there even though the resident kept telling her to stay out of the shower. In continued interview on 07/27/2023 at 9:00 AM, Resident #7 stated a rumor had gotten out all over the community about what was going on and the DON and the HR person called him/her into their offices to talk about the incidents. The resident stated he/she only admitted to the shower incidents because he/she was embarrassed and ashamed about the photos and did not want to get CNA #24 in trouble. Resident #7 stated he/she was afraid if he/she told the truth about the texting and photos, the facility would move him/her out, and he/she really liked it there and wanted to finish out his/her program. The resident stated the photos of CNA #24 topless, showing her bare breasts were sent through a social media app called Snapchat and the photos deleted after twenty-four (24) hours. Resident #7 stated he/she was now feeling harassed by CNA #24 because of her continuing to come to his/her room late at night and by her entering the shower room when he/she was unclothed and showering. The resident stated CNA #24 entered his/her room the other night on the 7:00 PM to 7:00 AM shift when she was not even assigned to work the Lotus Unit. Resident #7 stated LPN #1 saw CNA #24 coming in and out of his/her room that night and asked the CNA why she was on the unit when she was supposed to be working on another unit. Resident #7 stated after the incident, LPN #1 and LPN #11 came in and talked with him/her about why CNA #24 was in his/her room, and the resident told them the CNA would not leave him/her alone. The resident stated he/she told the LPN's about the shower incidents and that he/she was feeling harassed, shamed, and embarrassed by CNA #24 and by the facility managers who kept asking him/her about the relationship. Resident #7 further stated he/she did not want to get CNA #24 in trouble or cause her to get fired; however, just wanted her to leave him/her alone. In a phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated she had been working on the Lotus Unit where Resident #7 resided since February 2023. She stated she worked at a jail for fifteen (15) years prior to coming to work at the facility, and had a lot of experience working with clients who had substance abuse problems. LPN #1 stated she overheard staff talking on the unit on 07/24/2023, about something going on between CNA #24 and Resident #7. She stated her supervisor LPN #11 was there at the time, and she asked her if that information should be reported. LPN #1 stated her supervisor agreed it should be reported and made a call to the DON that night to report CNA #24 and Resident #7 being in a relationship. She stated she and LPN #11 went to talk with Resident #7 after hearing of the relationship, and the resident said he/she and CNA #24 had been talking, but he/she decided to cut it off. LPN #1 stated Resident #7 told them CNA #24 then started harassing him/her and invading his/her space. She stated she had Resident #7 sign a written statement which she gave to the Assistant Director of Nursing (ADON) at the end of her shift that morning. LPN #1 stated Resident #7 said he/she ended the relationship because he/she needed to work on his/her sobriety and CNA #24 did not accept it well. She stated Resident #7 told her he/she was embarrassed and uncomfortable talking about the relationship with CNA #24. In continued phone interview on 07/27/2023 at 8:00 PM, LPN #1 stated Resident #9 and Resident #13 told her CNA #24 had been harassing Resident #7 and told her there were pictures sent by CNA #24 on Resident #7's phone. LPN #1 stated she saw CNA #24 enter Resident #7's room on the Lotus Unit in the middle of the night when she was not assigned to the unit. She stated the DON knew about all of this and did not interview Resident #7 because she told the ADON to interview him/her. LPN #1 stated she tried to tell Resident #7 he/she was the victim in the situation and he/she needed to be honest and report it. She stated she reported the information to Unit Manager/Infection Prevention Nurse (UM/IP) #1 and Registered Nurse (RN) #2 who both defended CNA #24 and said Resident #7 was manipulating and taking advantage of the CNA. LPN #1 stated they made Resident #7 the perpetrator in the situation and revised his/her care plan to make the resident care in pairs and for seeking relationships with staff. In interview on 07/27/2023 at 8:50 PM, RN #3 stated she had been at the facility for almost two (2) years, and primarily worked the Lotus Unit. RN #3 stated there was an inappropriate physical relationship between CNA #24 and Resident #7, where the CNA was pursuing the resident and always going to his/her unit and into his/her room. The RN stated CNA #24 would constantly be wherever Resident #7 was and was always in his/her space. RN #3 stated she first heard about the inappropriate relationship between CNA #24 and Resident #7 about two (2) weeks ago and told the DON. She stated the DON said she would take care of it; however, RN #3 said she could not see where anything had happened after she reported the incident to the DON. The RN stated after a week went by, she heard about photos on Resident #7's phone. She stated Resident #9 reported having seen photos and text messages CNA #24 had sent to Resident #7, which included a naked photo. RN #3 stated after reporting the inappropriate relationship to the DON she started to received a lot of backlash from the DON, ADON, and the Unit Manager. She stated they gave her a lot a papers back to redo and said she was not doing her job. The RN stated after the backlash started she was too scared to say anything to the DON about the photos when she found out about them, so she told her brother about the relationship and he reported it in anonymously to the ED. In continued interview on 07/27/2023 at 8:50 PM, RN #3 stated she again noticed nothing was being done about the inappropriate relationship so she decided to make an anonymous call to the State to report it herself. She stated after it came out about the photos, Resident #7 was telling other residents and staff the facility's management team was badgering him/her and harassing him/her about it. According to RN #3, there were rumors all over the facility about what was going on with Resident #7 and CNA #24; however, none of the staff were doing anything about it. The RN stated Resident #7 was telling everyone CNA #24 was calling and texting his/her phone and harassing him/her and he/she just wished it would stop. RN #3 stated the Unit Manager told staff Resident #7 was a manipulator, and he/she would lie on staff and how was the management team to know that CNA #24 was not the victim in the situation. She further stated they made the victim, Resident #7, into the guilty party. In interview on 07/28/2023 at 2:45 PM, CNA #24 she stated she had been a CNA for fifteen (15) years and had worked at the facility through a staffing agency staff for about two (2) months. CNA #24 stated she had heard rumors she was having a relationship with a resident, came on to Resident #7, and was showing favoritism to him/her. She stated Resident #7 wanted to have a relationship, and she wanted to call the resident to set him/her straight. The CNA stated she had texted with Resident #7 and he/she also texted her, and sent a picture of his/her daughter and a shirtless picture of himself/herself to show he/she was gaining weight. CNA #24 stated she sent him/her pictures of herself and her kids, family type pictures; however, realized maybe she should not have done that. She stated the DON called her on Wednesday and said Resident #7 said he/she was being taken advantage of and he/she was vulnerable. The CNA stated she was told Resident #7 said she walked in on him/her in the shower, and she said she had done so by accident. CNA #24 stated the only time she visited Resident #7 in the middle of the night was if he/she asked her for something, and she stopped doing that because she did not feel like it was appropriate to go into his/her room late at night. In interview on 07/28/2023 at 4:00 PM, LPN #11 stated she worked as the night shift supervisor on the 11:00 PM to 7:00 AM shift and had been employed by the facility for three (3) years. LPN #11 stated if abuse allegations occurred staff were to immediately contact the ED who would then contact the DON, who who was supposed to start an investigation and suspend the worker during the investigation. LPN #11 stated she felt comfortable reporting allegations of abuse to the DON or ED. She stated she heard staff talking about an aide (CNA #24) being on the Lotus Unit and going into Resident #7's room when the aide was not assigned to work that unit and was also calling the resident on phone. The LPN stated she heard the aide looked Resident #7 up on Facebook and started having an inappropriate relationship with the resident that involved sending sexual pictures to the resident. She stated when she heard about the relationship, she contacted the DON who said they already knew about that information a week ago, and the DON told her the ED was already investigating it. LPN #11 stated she wrote a signed statement on 07/25/2023 at 12:14 AM, and gave it to the DON at the end of her shift. In continued interview on 07/28/2023 at 4:00 PM, LPN #11 stated the DON and ED moved CNA #24 to another unit the week before to prevent her from having contact with Resident #7; however, on 07/23/2023, she kept seeing the CNA going in and out of Resident #7's room. She stated she and LPN #1 went to talk with Resident #7 about the relationship and the resident said there was no relationship between him/her and CNA #24. The LPN stated LPN #1 had a better rapport with Resident #7, and asked her to leave the room so she could talk to the resident. She stated a few minutes later, LPN #1 called her back and Resident #7 told her he/she did have something going on with CNA #24; however, did not want it anymore because he/she was trying to get clean. LPN #11 stated Resident #7 reported CNA #24 kept bothering him/her and kept coming into his/her room. She stated the resident said he/she did not want to get anyone in trouble and that's why he/she had not said anything. The LPN further stated Resident #7 told her he/she just wanted CNA #24 to leave him/her alone. In interview on 07/29/2023 at 1:55 PM, the ED stated staff were to immediately report any signs of abuse to their supervisor or call him since he was the Abuse Coordinator. The ED stated abuse was to be reported in two (2) hours, and the report was to be sent to the State Agency (SA), Adult Protective Services (APS), and the Ombudsman. The ED stated on 07/20/2023 he received an anonymous call saying there were nude pictures which had been sent to a resident (Resident #7) by somebody only identified by her first name, no last name given. He stated Resident #7 and CNA #24 were interviewed and denied a relationship. The ED stated after discussing the incident with the Corporate VPO, they decided the incident was not reportable because everyone denied there being a relationship or that abuse had occurred on 07/20/2023. The ED stated the facility had not sent in a reportable on 07/20/2023, because after hearing the relationship between Resident #7 and CNA #24 was consensual, and since the resident had a BIMS of fourteen (14) and denied abuse, feeling stressed, or coerced, they felt it had not rose to the level of being reportable. In continued interview on 07/29/2023 at 1:55 PM, the ED stated a second allegation came in involving the same individuals on 07/24/2023, and he and the DON questioned Resident #7 again; however, the resident again said he/she was fine and did not feel abused. The ED stated he called HR to discuss what should be done about the second allegation and was told the allegation was not abuse and not reportable because the resident denied it happened. He stated on 07/26/2023, Resident #7 confided in his/her Peer Support Specialist (PSS) and a lot more information came out, and the Interdisciplinary Team (IDT) met as a QA team, and determined an investigation should be started. The ED stated after being made aware on 07/26/2023, of the 07/24/2023 allegation, it was determined the facility should have reported the incidents which occurred on 07/20/2023 and 07/24/2023 immediately to the State Agency as abuse. He stated in thinking about the 07/20/2023 incident, obviously we should have made a very different decision regarding the allegation, and it should have been reported because a caregiver in any role allegedly sending nude pictures to a resident was considered abuse. The ED further stated he expected all facility staff to follow the abuse process and policy. In interview on 07/29/2023 at 2:47 PM, the DON stated on 07/20/2023, the ED told her he received an anonymous call who said an employee identified by her first name had been sending inappropriate pictures to Resident #7. She stated she did not report the allegation to the State Agency (SA), Adult Protective Services (APS), or the Ombudsman because the ED already knew about it. The DON stated she did not know why the facility should have reported the allegation because Resident #7 denied the relationship occurred and the resident had a BIMS score of fourteen (14), and he/she had a right to a consensual relationship. She stated she did not think Resident #7 was a victim, and felt the resident manipulated CNA #24 and since they were both adults, they had the right to a consensual relationship. The DON stated she guessed the relationship between CNA #24 and Resident #7 should have been reported on 07/20/2023 though, when the initial call came in because it was an allegation of abuse. The DON stated all staff were to report abuse immediately so an investigation could be initiated, and the two (2) hour reporting time frame meant the facility had two (2) hours to investigate an abuse allegation before reporting it to the State Agency (SA), APS, and the Ombudsman. She further stated the QA team was meeting almost daily to discuss abuse; however, had not discussed the 07/20/2023 incident, as they had determined the allegation was not abuse. In interview on 07/29/2023 at 3:35 PM, the VPO stated the anonymous call received on 07/20/2023, regarding an inappropriate relationship between a staff member and a resident should not have been reported because Resident #7 had a BIMS score of fourteen (14) which indicated the resident was of sound mind, and he/she had the right to have a relationship of his/her own choosing. The VPO stated Resident #7 was interviewed about the incident several times and said nothing inappropriate was going on every time. The VPO stated we found out it was CNA #24, and the management team viewed the text messages in which Resident #7 stated over and over that he/she wanted a relationship with the CNA. He stated based on the text messages the incident was not a reportable event. The VPO stated the facility's process was for any allegation of abuse to be reported timely by the definition of the State Operations Manual (SOM), which would be within two (2) hours. He stated the Abuse Coordinator or designee should report abuse immediately; however, anyone could report an abuse allegation. In interview on 08/09/23 at 10:43 AM, the Regional Human Resource Business Partner (RHSBP) stated she was made aware the end of July, by the ED and DON, of an inappropriate relationship involving Resident #7 and CNA #24. The RHSBP stated she did not know the protocol, and that the allegation might be a reportable incident and informed the ED and DON they needed to do whatever needed to be done on that side of things. The RHSBP stated when the anonymous call with the allegation came through on 07/20/2023, it should have been reported based on the facility's policy. She stated that was what she told the ED, and she was not aware it had not been reported by the facility. The RHSBP stated she received another call on 07/26/2023, involving another allegation with the same resident and staff member and both admitted to the allegation at that time. She further stated staff had not been following the facility's policies but should have been doing so. 2. Review of Resident #1's Admission Record revealed the facility had admitted the resident on on 2/16/2022, with diagnoses to include Cognitive Communication Deficit, Unspecified Severe Protein-Calorie Malnutrition, Alzheimer's Disease, and Dementia. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating severe cognitive impairment. Review of the facility's Incident Report dated 12/12/2022 at 10:13 PM, revealed on 12/10/2022, Resident #1 came out of his/her room naked, saying please help me she hit me. Continued review revealed LPN #11 and CNA #33 assisted Resident #1 back to the room, dressed the resident, and helped him/her back to bed. Review of the Resident Description section revealed staff attempted to interview Resident #1, and the resident could not recall any events and denied any pain or discomfort, and no injuries were observed at time of incident. On 12/10/2022 CNA #33 told LPN #11 Resident #1 ran into the hallway yelling help me, she is hitting me. However, LPN #11 failed to report the allegation of abuse. (What document is it from? Progress Note? Incident Report? Please identify that source) Review of the Email submission sent by the ADON, revealed the incident had not been reported to the State Agency until 12/12/2022 at 10:07 PM. During an interview with LPN #11 on 7/18/2023 at 10:31 AM, she stated she had been in another resident's room administering medications, and when she exited the room she saw Resident #1 standing in the hallway naked. She stated CNA #33 walked up and assisted her in taking Resident #1 back into his/her room. LPN #11 stated they assisted Resident #1 to get dressed and back to bed. She stated CNA #33 then told LPN #11 she heard Resident #1 yelling Help me, she hit me. LPN #11 stated she did not hear Resident #1 say that so she did not report the incident. She stated she should have reported the incident even though she had not heard the resident yelling Help me, she hit me. She further stated any allegations of abuse should be reported immediately to the ED. During an interview with the Assisted Director of Nursing (ADON), on 7/18/2023 at 12:03 PM, she stated the unit manager, who was now the DON, called her on 12/12/2022 and asked her if she knew about an incident involving Resident #1 and asked if it had been reported. The ADON stated the now DON (former unit manager) said, CNA #33 told her Resident #1 came running into the hallway yelling Help me, she hit me on 12/10/2022. She stated she told the current DON/former unit manager she did not know about the incident. The ADON stated she reported the incident to the SA on 12/12/2022, after she being informed of the allegation of abuse. She stated LPN #11 should have reported the allegation of abuse to management immediately. The ADON further stated it was her expectation all staff follow the facility's abuse policy. During an interview with the current Director of Nursing (DON) on 07/19/2023 at 1:07 PM, who had been employed as the unit manager at time of the allegation, stated she became aware of the incident on 12/12/2022 when CNA #33 told her. She stated CNA #33 told her Resident #1 came running into the hallway yelling, Help me, she hit me. The DON stated LPN #11 should have notified the abuse coordinator immediately at the time CNA #33 informed her of the incident. The DON further stated all staff were to report allegations of abuse immediately to the ED even if they did not see it or hear it. During an interview with the Executive Director (ED) on 07/19/2023 at 1:21 PM, he stated the process for reporting allegations of abuse was to report all allegations immediately, and the facility had two (2) hours to report to the State Agency. The ED further stated the incident involving Resident #1 should have been reported immediately and staff had not followed the facility's policy.

Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, that would meet the resident's physical, mental, and psychosocial needs for one (1) of thirty-eight (38) sampled residents (Resident #48). On 05/29/2023, Resident #48 was found by the driver of a transportation company seated in the lobby of the facility in his/her wheelchair, alone and unresponsive. The driver of the transportation company attempted to locate the facility staff but was unable to locate staff to assist the resident, and he attempted to call the facility several times and no one answered the phone. Subsequently, the driver of the transportation company drove the resident to his/her dialysis appointment, which was approximately eight (8) minutes away from the facility. Once the resident arrived at the dialysis clinic, the transportation driver alerted the dialysis staff to assist the resident who was assessed as being unresponsive and sweating profusely. The dialysis clinic staff called 911 immediately and the resident was admitted to the hospital with diagnoses to include Altered Mental Status, Pulmonary Edema (a condition where fluid accumulates on the lung tissue), and respiratory distress. The facility's failure to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious harm or serious injury, impairment, or death to the residents if immediate action was not taken. Immediate Jeopardy (IJ) was identified on 08/11/2023 at 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on 05/29/2023 and is ongoing. The facility was notified of the Immediate Jeopardy on 08/11/2023. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, revealed residents with end-stage renal disease would be cared for according to currently recognized standards of care. Policy interpretation and implementation revealed that staff caring for residents with End-Stage Renal Disease (ESRD), including residents receiving dialysis care outside the facility, would be trained in the care and special needs of the residents. Education and training of staff included, specifically, a.) the nature and clinical management of ESRD (including infection prevention and nutritional needs); b.) signs and symptoms of worsening condition and/or complications of ESRD; c.) how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; d.) timing and administration of medications, particularly those before and after dialysis; e.) the care of grafts and fistulas; and f.) the handling of waste. Review of the facility's policy titled, Change in Residents Condition or Status, revised February 2021, revealed the facility would promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. Continued review revealed the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Further review revealed a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (was not self-limiting) or impacted more than one area of the resident's health status. Per the policy, prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact Situation-Background-Assessment-Recommendation (SBAR) Communication Form. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised March 2022, revealed the purpose of the comprehensive, person-centered care plan was to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the resident's care plan would reflect currently recognized standards of practice for problem areas and conditions. Continued review revealed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. Review of Resident #48's Admission Record revealed the facility had admitted the resident on 06/21/2020 with diagnoses to include End Stage Renal Disease (ESRD) stage 5; Diabetes Mellitus (DM), Congestive Heart Failure (CHF), Hypertension (HTN), Peripheral Vascular Disease (PVD), Right Above the Knee Amputation (RAKA), and Dysphagia. Review of Resident #48's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility had assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #48 to require extensive assistance of one (1) staff for bed mobility, dressing, toilet use (incontinent of bowel and bladder), personal hygiene; supervision of one (1) staff assistance for locomotion in his/her wheelchair on/off unit; setup supervision of one (1) staff for eating and bathing; extensive assistance of two (2) staff for transfers with the use of a mechanical lift. A continued review of Resident #48's MDS of special treatments revealed the resident had a diagnosis of End Stage Renal Disease (ESRD) with dependence on Hemodialysis (HD). Review of Resident #48's Comprehensive Care Plan, revealed Focus #1 to include the resident needed Dialysis HD related to ESRD with interventions that included: a Dietician consult; do not draw blood from or take blood pressure (BP) in arm with graft; monitor intake and output, monitor labs and report to the physician as needed, monitor vital signs as ordered and notify the physician of significant abnormalities, monitor/document/report as needed any signs/symptoms of infection; monitor/document/report as needed any signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds, bleeding, hemorrhage, bacteremia, and septic shock. Further review of Resident #48's Comprehensive Care Plan, initiated on 12/27/2022, revealed the resident was care planned for altered respiratory status/difficulty breathing related to a history of Congestive Heart Failure. The goal of the care plan included: the resident would have no s/signs and symptoms of poor oxygen absorption through the review date. Further review of the care plan revealed interventions included: Administer medication/puffers as ordered; monitor for effectiveness and side effects; assist the resident/family/ caregiver in learning signs of respiratory compromise; elevate head of bed (HOB) to prevent shortness of breath (SOB) while lying flat. Continued review of the resident's Comprehensive Care Plan related to altered respiratory status, initiated on 12/27/2022 revealed further interventions to include: monitor /document changes in orientation; increased restlessness; anxiety; and air hunger; monitor for signs and symptoms of respiratory distress and report to the Medical Director (MD) as needed (PRN): when the resident experiences increased respirations; decreased pulse ox; increased heart rate (Tachycardia); restlessness; Diaphoresis (abnormal sweating); Headaches; Lethargy; and Confusion. However, the facility failed to implement the resident's interventions, including continuous monitoring, and assessing the resident for a change in condition, lethargy, and assessing the resident's respiratory by monitoring and documenting the resident's changes in orientation. Review of Resident #48's Advanced Registered Nurse Practitioner (ARNP) Regulatory Visit Note, dated 05/23/2023 at 4:00 PM, revealed the ARNP assessed the resident to have a cough, unspecified, and coughing after every bite of food or drink. Further review revealed the ARNP recommended having the Speech Therapist (ST) evaluate and treat the resident for concerns related to aspiration (when something swallowed goes down the wrong way and enters the airway or lungs). Review of Resident #48's Nurse's Notes dated 05/23/2023 at 7:29 PM, documented by Licensed Practical Nurse (LPN) #18, revealed the resident had a change in condition and was assessed to cough with his/her dinner. Continued review revealed no signs or symptoms (s/s) of distress was noted. Review of Resident #48's Speech Evaluation, dated 05/24/2023, completed by the Speech Language Pathologist (SLP) revealed she assessed the resident for his/her coughing after every bite of food or drink. Further review of the SLP evaluation revealed she recommended no further testing; however, recommended supervision for oral intake and strategic positioning of ninety (90) degrees upright, small bites/sips, thorough chewing, at a slow rate, and avoiding tough consistencies. However, the Speech Language Pathologist's recommendation was not added to the resident's care plan to prevent the resident from aspirating. Review of Resident #48's Nurse's Notes dated 05/29/2023 at 2:16 AM, entered by LPN #17 revealed the resident was resting in his/her bed with no signs and symptoms (s/s) of swelling or pain noted. However, there was no documented evidence to support the LPN implemented the resident's care plan which included assessing the resident for his/her altered mental status, vitals, and/or altered respiratory distress , prior to the resident being transported to his/her dialysis treatment at approximately 6:10 AM. Review of Resident #48's Dialysis Center Note dated 05/29/2023, revealed the resident arrived for his/her treatment at 6:16 AM and was unable to be aroused by multiple staff members. The resident was noted to be sweating profusely and leaning over to his/her right side, his/her tongue was protruding, and he/she had a large amount of drool and chewing tobacco falling from his/her mouth. Further, the resident had respirations of 22 (the normal respiratory rate for an adult is 12 to 20 breaths per minute at rest) and labored. Continued review of the Note revealed the resident did not respond to sternal rub or verbal commands. Staff from the Dialysis Center called 911 for the resident to be transported to the emergency room (ER). Review of Resident #48's Hospital Records dated 05/29/2023, revealed the resident presented to the emergency room (ER) with altered mental status, required fifteen (15) liters (L) of a non-rebreather to maintain a stable oxygen (O2) saturation, the resident's chest x-ray showed diffuse pulmonary edema (fluid on the lungs, making it difficult to breath). Further review of the ER Hospital Record revealed the resident was intubated (ventilation) and placed on the ventilator for airway protection and oxygen support. Resident #48 was diagnosed with acute hypoxemic respiratory failure (not enough oxygen in the blood) from pulmonary edema. During an interview on 08/11/2023 at 11:44 AM, Certified Nursing Assistant (CNA) #33 stated prior to his shift, he would go to the unit supervisor and nurse to get a full report; discuss the residents that were on dialysis, and isolation, had changes in their condition, and anything important about the residents. Also, he would review the resident's Kardex (the nurse aide's care plan), to provide care to the residents. CNA #33; however, stated he did not recall Resident #48, nor any residents on his shift that had any issues the night/morning of 05/29/2023, or any other time that he could recall. CNA #33 stated he would assist in getting dialysis residents up in the mornings between 4:30 AM to 5:00 AM, provide personal care and assist with dressing and transferring the residents into their wheelchairs. Further, he stated that after the residents were dressed, he would assist with taking the residents to the nurse's station for the nurse to take over the resident's care. Per the interview, the CNA stated the nurse was responsible for assessing and performing vital signs on the residents prior to dialysis. CNA #33 added he had not assisted with the transfer of any dialysis residents to the lobby of the facility, nor stayed to supervise those residents until transportation arrived, adding, that would be the nurses' responsibility. During an interview on 08/11/2023 at 2:21 PM, CNA #32 stated she worked through the agency since May 2023. CNA #32 stated she would not be responsible for assessing the residents for their vital signs. She further stated the nurses would assess the residents. CNA #32 stated if she observed any change in a resident's status; new symptoms, such as a resident not feeling well and/or a change in their mental status, she would advise the nurse. In a continued interview with CNA #32, she stated CNAs would clean the residents, get them up for transfer, take them to the nurses' station and the nurse would take over the resident's care. The CNA stated she could not recall any residents with any problems before leaving for dialysis; however, she did not transfer residents to the lobby area of the facility, nor sit with the residents for pickup. Therefore, she could not say if the residents were experiencing any change in status and/or were in respiratory distress once she left the resident at the nurses' station. The CNA stated she thought it was normal practice; standards of nursing care that residents would be assessed and monitored prior to leaving the facility for an appointment. During an interview on 08/10/2023 at 7:25 PM with LPN#16 (agency nurse), she stated she had worked at the facility a few months and had only worked with Resident #48 a few times. She stated she remembered Resident #48 went to dialysis and that they had to get him/her up with the Hoyer Lift. She stated the process for dialysis residents was to get them up in a wheelchair, give them their snacks before they go, and take them to the lobby to wait for transportation. She stated as the nurse, she was responsible for passing medications, doing treatments, and assisting the aides when needed. She stated she was also responsible for getting the resident's vital signs and putting them in the resident's binder they would take with them to dialysis. She stated she did not have to document the resident's vital signs in Point Click Care (PCC). Per the interview, she stated after the aides got the residents up for dialysis, they would take the residents to the front lobby to wait by the door for transportation to come pick them up. She stated she did not know if anyone had to stay with the resident while they waited for transportation. She stated if a resident appeared to be in distress, she would have called the doctor and the resident would not have been transported to dialysis. During an interview on 08/10/2023 at 3:35 PM with Licensed Practical Nurse (LPN) #17, she stated residents who were on dialysis would be assessed upon return from dialysis. She stated dialysis residents would normally leave between 5:30 AM and 6:30 AM; however, the residents were gone before dayshift clocked in. LPN #17 further stated Resident #48 had a normal mental status and routinely he/she was up and moving in his/her wheelchair. LPN #17 stated prior to sending residents to dialysis, nurses were responsible for completing an assessment. She stated that if any issues during the assessment, such as changes in the resident's condition, which would include the resident being lethargic and unstable vital signs, then the resident would not go to dialysis and the physician would be notified. LPN #17 added, the facility had dialysis binders, that were resident-specific, that were located at the nursing stations with the resident's identity, vital signs, and changes. In addition, LPN # 17 stated she had not assessed the resident on 05/29/2023 and stated it was the night shift nurse's responsibility. She stated she was never informed of any changes or concerns that the resident had the night prior to dialysis on 05/29/2023. During an interview on 08/11/2023 at 2:21 PM with the Transportation Driver, he stated he was familiar with Resident #48 and stated he had been the resident's driver for over two (2) years. Per the interview, the driver stated he transported the resident to the dialysis clinic/center on Mondays, Wednesdays, and Fridays to the Dialysis Center at 6:00 AM. The driver stated the drive from the facility to the dialysis center was approximately nine (9) minutes; therefore, he would arrive at the facility approximately (20) minutes early, to ensure the resident arrived to his/her dialysis appointment on time. In a further interview with the Transportation Driver, on 08/11/2023 at 2:21 PM, he stated on 05/29/2023, he arrived at the facility at approximately 5:40 AM and could visually see Resident #48 sitting in the front lobby, without supervision. He added, the resident appeared to be sleeping with his/her head hung over in the wheelchair; therefore, he attempted to phone the resident several times, as normal routine on his/her cell phone. The driver, however, stated that on this day the resident would not answer his/her calls, as the resident appeared asleep through the front lobby window. Therefore, the driver stated due to him/her not having access to the facility's front door, he attempted three (3) times to call the facility due to no one being with the resident to open the front door, but no staff would answer the phone. Further interview, on 08/11/2023 at 2:21 PM, the driver stated, at approximately 6:01 AM, a staff member opened the facility door to allow the driver into the facility to assist the resident to the van. The driver stated he addressed the resident by stating, hello, however, the resident did not respond. Continued interview with the driver revealed he thought the resident was sleeping. Therefore, the driver stated he continued to transport the resident to the clinic; however, the resident did not interact with the driver during the transport, which was not the resident's normal behavior. Per the interview, the driver stated that once they arrived at the destination, the resident was not responding. He stated the resident was pale and weak and felt something was not right with the resident. The driver stated he immediately made the dialysis staff aware of the resident's condition. During an interview on 08/10/2023 at 2:01 PM with Dialysis Nurse #1, she stated she was Resident #48's nurse on 05/29/2023, at approximately 6:15 AM. Per the interview, she stated the resident was observed in his/her wheelchair slumped over, sweating profusely, and added the resident's shirt was soaked. Further, she stated the resident's skin was cold and clammy, his/her tongue was protruding outside of his/her mouth, as well as drool and chewing tobacco secretions coming out. Dialysis Nurse #1 stated the transportation driver had just dropped the resident off, and she was unsure how long the resident had presented with these types of symptoms. She stated she was unsure if any other nurse at the Dialysis Clinic had received a report from the transportation driver; however, she stated the resident was not responding to her voice nor several staff sternal rub attempts. Dialysis Nurse #1 stated she contacted Emergency Medical Services (EMS) with the resident remained unresponsive. She further stated she attempted to contact the facility several times by phone, to obtain the resident's assessments related to his/her vital signs, mental status, and medication administration, prior to the resident leaving the facility on the morning of 05/29/2023; however, she was unable to reach anyone at the facility. During an interview on 08/11/2023 at 12:11 PM with the Advanced Registered Nurse Practitioner (ARNP), stated she was very familiar with Resident #48 and would provide regulatory visits every month and/or as needed. ARNP stated Resident #48 was readmitted to the facility in May 2023, from the hospital on continuing antibiotics related to pneumonia with a pleural effusion that had not been resolved, and the resident developed a cough that would not subside. The ARNP stated, since Resident #48's return from the hospital she felt the resident was mentally sharp, alert and oriented; however, physically fragile and he/she would attempt to self-propel and stay up in his/her wheelchair most of the day. The ARNP added she was aware Resident #48 chewed tobacco, she was concerned from her regulatory visit/assessment on 05/23/2023, of the resident's cough after every bite of food and/or drink; therefore, she ordered a chest x-ray and consult for a Speech Language Pathologist (SLP) evaluation. In addition, ARNP stated she would have expected the SLP recommendations to be followed through and care planned appropriately and immediately for the safety and wellbeing of her resident. In addition, ARNP stated she also would have expected Resident #48 to have been care planned appropriately for chewing tobacco use related to risk of aspiration. The ARNP stated that since the resident's return from the hospital, he/she had not been himself/herself and was weak and fragile. During an interview on 08/11/2023 at 4:51 PM with the Assistant Director of Nursing (ADON), she stated that it was the expectation that with dialysis residents, staff would get the resident up, check their vital signs and nurses would perform an assessment and document all findings on the dialysis communication sheet, as well as, document in the nurse progress notes. Per the interview, she stated staff would transport the resident to the common area in the front lobby to wait until transportation arrived. The ADON stated those residents would not need one-on-one supervision due to staff walking the halls, so they would see the residents constantly and have eyes on the resident. She further stated that the normal procedure would be for transportation to ring the doorbell and a staff member would answer the door. The ADON further stated that if no one answered the door, transportation should have called the facility. However, interview with the transportation driver revealed he called the facility three (3) times and no one answered the facility's phone. During an interview on 08/11/2023 at 5:00 PM, with the Director of Nursing (DON), she stated she did not require her staff to obtain vital signs, weights and/or assessments prior to the resident leaving the facility for dialysis but would attain upon the residents return to the facility. The DON added staff could sit residents in the front lobby to wait for transportation; however, there should have been a staff member in the front lobby to allow visitor access into the facility or answer the phone in a timely manner. The DON stated it would have been her expectation that the speech therapy recommendations would be followed up with the Medical Director and/or ARNP and discussed in the Interdisciplinary Team (IDT) meeting, and the morning Clinical Meetings, and should have been care planned by the Minimum Data Set (MDS) Coordinator; however, anyone could have care planned as soon as possible. In addition, the DON stated if a resident was unresponsive, staff should never place that resident in the lobby, unsupervised and the nurse should have assessed the resident. Further, she stated the physician should have been notified to obtain further orders, in order to ensure the resident's safety. Continued interview with the DON revealed it was her expectation that nursing would have assessed all residents prior to leaving the facility for dialysis, especially if altered mental status was noted. During an interview on 08/11/2023 at 5:25 PM with the Medical Director (MD), he stated he was in the MD position less than a year. He expected staff to follow the facility policies and would expect a resident to be assessed if they presented with altered mental status. The MD stated, for medical necessity, he would expect staff to follow the speech therapist recommendations and would expect all recommendations to be care planned appropriately. He further stated, if a resident was chewing tobacco, he/she should have been care planned appropriately to prevent the risk of aspiration. In addition, the MD stated he would expect the facility to keep him informed or to notify the ARNP of resident changes in condition, for the safety and well-being of the resident. During an interview on 08/11/2023 at 5:33 PM with Executive Director (ED), stated he would expect staff to follow the recommendations of the therapist for the safety of the residents. He further stated the recommendations should have been care planned and discussed with the resident and/or the Resident Representative (RP), so the IDT and staff were on the same page and that all staff knew what care needed to be provided. The ED stated the resident should have been care planned appropriately for his/her safety. Further, he stated, if a resident was found unresponsive, he would have expected staff to assess the resident, act immediately, and call the MD for recommendations. Additionally, the ED stated he would have expected staff to utilize the MD as a resource daily, and the MD to participate in Quality Assurance Performance Improvement (QAPI) and assist to make recommendations as needed to assist the facility in running safely and efficiently.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure there was a system in place to prevent the diversion of the resident's-controlled drugs for eight (8) out of thirty-nine (39) sampled residents (Resident #6, Resident #11, Resident #10, Resident #16, Resident #21, Resident #23, Resident #25, and Resident #42). On 05/24/2023, the Narcotic count at 3:00 PM revealed Resident #6 was missing five (5) Gabapentin; Resident #11 was missing one (1) Gabapentin; and Resident #10 was missing one (1) Tramadol. The facility's investigation determined the Licensed Practical Nurse (LPN) #13 had signed out too many pills that could not be accounted for. On 07/12/2022 Residents #16, #21, #23, #25, and #42 had Hydrocodone that was signed out by Licensed Practical Nurse (LPN) #14. Record review revealed the LPN documented the residents received their medications. However, review of the facility's investigation revealed the residents stated they did not receive their medications. The findings include: Review of the facility's policy titled, Residents Rights, not dated, revealed each resident had the right to be free from abuse, neglect, misappropriation of the resident's property, and exploitation. Review of the facility's policy titled, Controlled Substance, dated 08/27/2018, revealed when using controlled substances, the law required the doctor to hand write the prescription. Further review of the policy revealed the pharmacist filling the prescription would maintain records of the amount of drug-filled for each resident. The records maintained by the pharmacist were periodically reviewed by the Federal Drug Administration. A continued review of the policy revealed staff-maintained records of the controlled substances stored in the community, as well as, the dose given to the resident. Continued review revealed it was essential to make certain the resident requiring the controlled substance received the medication as ordered by the physician. Further review revealed the storage of the controlled substances would be strictly monitored. A review of the facility's five (5) Day Follow-Up Investigation, 05/29/2023, revealed Resident #6 was missing five (5) of his/her Gabapentin (used to treat pain) tablets, Resident #10 was missing one (1) Tramadol (used to treat pain), and Resident #11 was missing one (1) Gabapentin on 05/24/2023. Continued review revealed Licensed Practical Nurse (LPN) #13 stated she had counted the medications with LPN #8 at the beginning of the shift and the count was correct. Further, review revealed LPN #13 stated she counted the cart with Certified Nurse Aide/Certified Medication Technician (CNA/CMT) #29 at the end of her shift on 05/23/2023 and the count was correct. Continued review revealed CNA/CMT #29 stated she counted the cart with LPN #13 and the count was off and she asked LPN #13 what had happened. Per the facility's investigation, LPN #13 stated she had to waste (disposal of a medication that was not used) the pills and CNA/CMT #29 and LPN #13 corrected the drug count at that time. Additional review of the five (5) Day Follow-up Investigation revealed LPN #13 and CNA/CMT #29 were both suspended pending the outcome of the investigation. 1. Review of Resident #6 Admission Record revealed the facility admitted the resident on 02/19/2020 with diagnoses which included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease (CKD) stage 4, Diabetes Mellitus (DM), Hypertension (HTN), Atrial Fibrillation (AFib), Paraplegia, Major Depression, and Anxiety. Review of Resident #6's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #6's Physician Orders dated May 2023 revealed an order to administer Gabapentin Capsule 300 milligrams (MG) and give one (1) capsule by mouth two times a day for Pain. Review of Resident #6's Gabapentin Controlled Drug Receipt/Record/Disposition Form dated May 2023 revealed five (5) Gabapentin 300 mg capsules were unaccounted for at the end of shift count on 05/24/2023 at 4:00 PM. During an interview with Resident #6, on 08/03/2023 at 4:40 PM, he/she stated he/she did not remember having any Gabapentin missing. Resident #6 further stated his/her pain level had never been out of control. During an interview with CNA/CMT #29, on 08/07/2023 at 4:30 PM, she stated she remembered counting the cart in May and there was a discrepancy in the cart count when she was counting with LPN #13. She stated she noticed five (5) Neurontin (used to treat pain) pills were missing for Resident #6 and when she asked LPN #13 about it, LPN #13 stated she dropped all five (5) pills. CNA/CMT #29 stated she let LPN #13 correct the card for the 5 missing pills and the LPN documented she had dropped the medications. The CNA/CMT stated she took receipt of the cart and reported it to the Assistant Director of Nursing (ADON) the next morning. Per the interview, the CNA/CMT stated she had to write a statement about what had happened to the resident's medications. Further, she stated the DON and ADON suspended CNA/CMT #29 and LPN #13 until they completed the investigation. CNA/CMT #29 stated she was allowed to come back to work but LPN #13 was not allowed to return because the investigation revealed there were too many medications missing while LPN #13 had control of the medication cart. The Director of Nursing (DON), during an interview on 08/10/2023 at 12:10 PM, stated on 05/24/2023, after conducting the investigation into Resident #6's missing Gabapentin, Resident #10's missing Tramadol, and Resident #11's missing Gabapentin, it was determined LPN #13 had to be terminated. Further, she stated the facility had found too many errors with LPN #13's math when reviewing the Narcotic records, adding, the numbers did not add up with the numbers from the pharmacy and on the Controlled Drug Record. The DON stated the LPN was terminated. 2. Review of Resident #10's Admission Record revealed the facility admitted the resident on 11/03/2022 with diagnoses that included: Osteoporosis, Wedge Compression Fracture of the thoracic vertebra, Alcoholic Hepatitis, and Depression. Review of Resident #10's Quarterly MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #10's Physician Orders dated May 2023 revealed an order to administer Tramadol HCl 50 MG, give one (1) tablet by mouth every eight (8) hours for Pain. Review of Resident #10's Tramadol Controlled Drug Receipt/Record/Disposition Form dated May 2023 revealed Resident #10 was missing one (1) Tramadol 50 mg capsule at the end of shift count on 05/24/2023 at 4:00 PM. During an interview with Resident #10 on 08/03/2023 at 4:45 PM, he/she stated he/she recalled a time when he/she did not receive his/her Tramadol; however, could not remember the date or if he/she had been having pain at that time. Resident #10 stated he/she usually received his/her medications on time and whenever he/she asked for them. Resident #10 stated he/she did not have any concerns and that his/her pain level was always under control. 3. Review of Resident #11's Admission Record revealed the facility had admitted the resident on 04/12/2020 with diagnoses to include: End Stage Renal Disease (ESRD), Traumatic Brain Injury (TBI), Dementia, Above Knee Amputation (AKA), and Pain. Review of Resident #11's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), indicating the resident had moderate cognitive impairment. Review of Resident #11's Physician Orders dated May 2023 revealed an order to administer Gabapentin Capsule 300 milligrams (MG), give one (1) capsule by mouth two times a day for Pain. Continued review revealed the medication had been discontinued on 05/01/2023. Further review revealed a new order for Gabapentin Capsule 100 MG (CAPS), give two (2) capsules by mouth every eight (8) hours for Neuropathy. The State Survey Agency (SSA) surveyor requested a copy of Resident #11's Gabapentin Controlled Drug Receipt/Record/Disposition Form dated May 2023 to validate the resident was missing one (1) Gabapentin the end of shift count on 05/24/2023. However, the facility failed to provide the SSA surveyor a copy of the form. During an interview with Resident #11, on 08/07/2023 at 12:55 PM, he/she stated his/her pain had never been out of control and the nurses gave his/her medications as scheduled. The SSA surveyor attempted a telephonic interview with LPN #13, on 08/07/2023 at 4:10 PM and again on 08/08/2023 at 9:45 AM. The LPN did not answer or return the surveyor's call. In an interview with the Assistant Director of Nursing (ADON), on 08/09/2023 at 2:15 PM, she stated on 05/24/2023, Resident #6 was missing five (5) Gabapentin, Resident #10 was missing one (1) Tramadol, and Resident #11 was missing one (1) Gabapentin at the beginning of shift narcotic count with CNA/CMT#29 and LPN #13. The ADON further stated, LPN #13 had been terminated at the conclusion of the facility's investigation due to identified errors when reviewing the Narcotic Count Sheets, and the pharmacy manifestation records. Per the interview, she stated the numbers did not add up and the LPN's math was incorrect. Review of the facility's 5-Day Follow-Up Investigation, dated 07/12/2022, revealed nursing management was made aware of a problem regarding several residents who stated they had not received their pain medication last Thursday PM shift and going into Friday AM shift, on 07/07/2022 through 07/08/2022. Per the residents' statements, narcotic medications from 07/07/2022 through 07/08/2022 were not administered. However, those medications were signed out in the narcotic book. Upon review of the nursing narcotic book, those residents had narcotic medications signed out as given by the nurse (LPN #14), for a time she was not on the unit. Medication carts were all counted for accuracy. Residents were interviewed and all denied any concerns with care or receiving narcotics on a regular basis, except for this night. 4. Review of Resident #16's Closed Admission Record revealed the facility admitted the resident on 01/04/2021, with diagnosis to include Cerebral Vascular Accident CVA, Hemiplegia affecting left nondominant side, Hypertension (HTN), unspecified dementia with mood disturbance, Major Depressive Disorder (MDD), Attention Deficit Disorder (ADD), and Dysphagia. Review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #16's Medication Administration Record (MAR) revealed an order to administer Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen), start date 06/28/2022, one (1) tablet by mouth every six (6) hours as needed for pain. Continued review of Resident #16's Medication Administration Record (MAR) revealed the resident's pain medication was administered on 07/08/2022 at 12:00 AM, by LPN #14; however, the medication was documented as administered before LPN #14 arrived on the unit. Review of Resident #16's Hydrocodone-Acetaminophen Controlled Drug Receipt/Record/Disposition Form, dated July 2022, revealed Resident #16's Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) was accounted for at the end of shift count on 07//08/2022 at 1:00 AM and 07/08/2022 at 7:00 AM, with no discrepancies noted. Review of the witness statement for Resident #16, dated 07/12/2022, revealed the resident informed the DON that his/her pain medication had not been requested or administered. 5. Review of Resident #21's Closed Admission Record revealed the facility admitted the resident on 04/28/2022, with diagnoses that included: Orthopedic aftercare following surgical amputation, acquired absence of Right Leg Below Knee Amputation (BKA), Diabetic Neuropathy, Depression, and Alcohol Abuse. Review of Resident #21's Admission Minimum Data Set (MDS), dated [DATE] revealed the facility had assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #21's Medication Administration Record (MAR) revealed an order to administer Norco Tablet 5-325 MG (Hydrocodone-Acetaminophen), start date 06/20/2022, one (1) tablet by mouth every four (4) hours as needed for pain. Review of Resident #21's Hydrocodone-Acetaminophen Controlled Drug Receipt/Record/Disposition Form dated July 2022, revealed Resident #21's controlled drug medication was accounted for with no discrepancies noted on 07/08/2022 at 1:00 AM and 07/08/2022 at 7:00 AM. Review of the witness statement for Resident #21, dated 07/12/2022, revealed the resident informed the DON that other residents were discussing not receiving medication from 07/07/2022 to 07/08/2022. Resident #21 stated he/she then asked the nurse to just check and see if he/she had medication signed out for that date. In addition, Resident #21 stated he/she was an LPN and was fully aware of what was going on. 6. Review of Resident #23's Closed Admission Record revealed the facility had admitted the resident on 06/23/2022, with diagnoses which included: unspecified Closed Fracture of the right lower leg, Diabetic Neuropathy, Major Depressive Disorder, Other Psychoactive Substance Abuse and pain in the ankle and joints of foot. Review of Resident #23's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #23's Medication Administration Record (MAR), start date of 06/23/2022, revealed staff was to administer Norco Tablet 10-325 MG (Hydrocodone-Acetaminophen), and give one (1) tablet by mouth every four (4) hours as needed for severe pain. Continued review revealed it was documented the resident's-controlled drug was administered on 07/08/2022 at 1:00 AM and 5:00 AM with a pain score of five (5); however, the resident stated he/she did not receive the 1:00 AM dose. The resident reported he/she had received the 5:00 AM dose only. Review of Resident #23's Hydrocodone-Acetaminophen Controlled Drug Receipt/Record/Disposition Form dated July 2022 revealed Resident #23's Norco Tablet 10-325 MG (Hydrocodone-Acetaminophen), was accounted for at the end of shift count on 07/08/2022 at 1:00 AM and 07/08/2022 at 7:00 AM, with no discrepancies noted. Review of the witness statement and investigation for Resident #23, dated 07/12/2022, revealed the resident stated LPN #14 told Resident #23 that his/her medication had not arrived from the pharmacy and told the resident that he/she was out, when in fact his/her narcotic medications were entered onto the medication cart and the narcotic book by LPN #14 and the off-going nurse, Registered Nurse (RN) #1, that night during count. Resident #23's medication had been signed out at 12:00 AM and 5:00 AM by LPN #14; however, the resident stated he/she only received his/her 5:00 AM dose. During an interview, on 08/03/2023 at 10:18 AM, with Registered Nurse (RN) #1, she stated she was responsible for ensuring residents received their medications and as needed (PRN) pain medications in a timely manner and ensuring the accuracy of narcotic counts. RN#1 stated the process was to count all resident narcotics on shift change as the off-going nurse would keep the keys until the count was completed and accurate. She further stated that if a discrepancy occurred, the Executive Director (ED) and Director of Nursing (DON) would be notified and the nurse/CMT would wait until one of them was present to assist with count and take over. Further, she stated the facility would conduct an investigation and the keys would be handed over to them (them ?) at that time. RN #1 stated she had not encountered any discrepancies with narcotic counts and/or resident narcotics not being accountable. RN #1 stated she had worked with LPN #14 and did not have a concern with the LPN's administration of the resident's medications, though she stated she had not witnessed the LPN administer medications to the residents. RN #1; however, stated she could not recall the date of the incident related to the diversion of the resident's medications with LPN #14, but remembered she was interviewed related to drug diversion as the residents complained they had not received their pain medications. 7. Review of Resident #25's Closed Admission Record revealed the facility had admitted the resident on 05/10/2022, with diagnoses which included: disease of spinal cord, fusion of spine; cervical region, Spondylosis with Myelopathy; cervical region, Spinal Stenosis, Cervicalgia, Psychoactive Substance Abuse, Paresthesia of skin and generalized muscle weakness. Review of Resident #25's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #25's Medication Administration Record (MAR) revealed Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen), start date 06/20/2022, was to be administered one (1) tablet by mouth every six (6) hours as needed for pain. LPN #14 documented the resident was administered his/her pain medications on 07/08/2022 at 12:00 AM with a pain score of five (5). Review of Resident #23's Hydrocodone-Acetaminophen Controlled Drug Receipt/Record/Disposition Form dated July 2022 revealed Resident #23's medication was accounted for at the end of shift count on 07/08/2022 at 12:00 AM and 07/08/2022 at 7:00 AM, with no discrepancies noted. Review of the witness statement and facility's investigation for Resident #25, dated 07/12/2022, revealed the resident stated he/she did not take medications late into the night, was asleep and did not receive his/her medications. Resident #25 then stated he/she did not need his/her pain medications a lot and only required them during the day after or before therapy; however, the resident's medication was signed out at 12:00 AM by LPN #14. 8. Review of Resident #42's Closed Admission Record revealed the facility had admitted the resident on 06/06/2022, with diagnoses that include Diverticulitis of large intestine with perforation and abscess without bleeding, colostomy status, Hypertension (HTN), Alcohol Abuse, Acute Posthemorrhagic Anemia, Depression, Anxiety, Seizures, and Insomnia. Review of Resident #42's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #42's Medication Administration Record (MAR), start date 06/10/2022, revealed staff was to administer Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen), one (1) tablet by mouth every six (6) hours as needed for pain. Continued review revealed the medication was documented to have been administered on 07/08/2022 at 12:00 AM and at 6:00 AM with a pain score of four (4). Review of Resident #42's Hydrocodone-Acetaminophen Controlled Drug Receipt/Record/Disposition Form dated July 2022 revealed Resident #16's medication was accounted for at the end of shift count on 07/08/2022 at 1:00 AM and 07/08/2023 at 7:00 AM, with no discrepancies noted. Review of the witness statement and facility investigation for Resident #42, dated 07/12/2022, revealed the resident stated he/she did not receive his/her pain medications that were signed out for 12:00 AM and 6:00 AM by LPN #14. During an interview on 08/07/2023 at 11:10 AM, with the former Director of Nursing (DON), she stated during the time of this diversion (07/07/2022 thru 07/08/2022), medication errors had been discovered during audits of all the resident records. The DON revealed her findings included multiple residents' medications were signed out early for PRN medications. Per the interview, the DON stated she had had previous concerns related to discrepancies related to the residents' medications and determined LPN #14 was a common factor; therefore, the facility terminated LPN #14 and the ED reported her to the Kentucky Board of Nursing (KBN) boards on grounds of narcotic diversion, narcotic waste that had been entered with no cosigner in the narcotic record, and one (1) occasion of forgery for a waste. During an interview with the current DON on 08/10/2023 at 12:10 PM, she stated drug diversion meant narcotics were missing and unaccounted for. She further stated, medications did not have to be missing to be drug diversion. The DON stated the process for conducting the investigation into drug diversion started with the employees being suspended pending the outcome of the investigation. The DON then stated she and the ADON and Unit Managers would conduct audits on all MAR's, interview residents to see if they had increased pain, and audit delivery manifest sheet. She stated nursing staff would look at the residents who were not interviewable for signs and symptoms of pain and review their MAR's. The DON stated medications were delivered by an outside Pharmacy and two (2) nurses had to check the Manifest delivery sheets with the narcotic sheets to make sure all the numbers were correct. Both nurses would then sign in the medications and add them to the cart and Narcotic sheets in the Narcotic book. The DON stated that if a discrepancy was identified, the facility would count the carts, look through the whole cart to make sure the medication had not accidentally popped out somewhere, and if the pills could not be located the nurse would be suspended pending the outcome of the investigation. During an interview with the Executive Director (ED), on 09/09/2023 at 4:31 PM, he stated he expected all the nursing staff administering medications to follow the facility's Residents' Rights Policy, Freedom from Misappropriation Policy, Controlled Substance Policy, and Medication Diversion Process to ensure medications were being administered correctly, per physicians' orders, and to prevent medications from being diverted from residents.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident had communication with and access to persons and services inside and outside the facility for one (1) out of thirty-nine (39) sampled residents, Resident #48. On 05/29/2023 the transport driver arrived at the facility to pick up Resident #48 for transport to the Dialysis Center and found Resident #48 alone in the lobby and unable to answer the phone to allow the driver into the facility. The driver attempted to call the facility several times and no one answered the phone to let the driver in. The driver stated he had to wait several minutes outside the facility until a staff member reporting for their shift arrived and opened the door so he could transport Resident #48 to the Dialysis Center. In addition, Resident #48 arrived to the Dialysis Center unresponsive the Dialysis Center attempted to call the facility several times to communicate a change in Resident #48's condition upon arrival to the center. The first time a call was attempted, the center was transferred but no one answered, and the second and the third time no one answered the call. Emergency Medical Services (EMS) arrived at 6:40 AM at the Dialysis Center to transport Resident #48 to the hospital for further evaluation. The findings include: Review of the facility's policy titled, Residents Rights, not dated, revealed employees should treat all residents with kindness, respect, and dignity. These rights included: the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation. Per the policy, the resident also had the right of communication with and access to people and services, both inside and outside the facility. Review of Resident #48's Admission Record revealed the facility admitted the resident, on 06/21/2020, with diagnoses to include End Stage Renal Disease (ESRD), Stage 5; Diabetes Mellitus (DM), Type 2; Congestive Heart Failure (CHF); Right Above the Knee Amputation (RAKA); and Dysphagia. Review of Resident #48's Quarterly Minimum Data Set (MDS) Assessment, dated 05/08/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Interview with the Transportation Driver, on 08/11/2023 at 2:21 PM, he stated on 05/29/2023, he arrived at the facility at approximately 5:40 AM and could visually see Resident #48 sitting in the front lobby, without supervision. He added, the resident appeared to be sleeping with his/her head hung over in the wheelchair; therefore, he attempted to phone the resident several times, as normal routine on his/her cell phone. The driver, however, stated that on this day the resident would not answer his/her calls, as the resident appeared asleep through the front lobby window. Therefore, the driver stated due to him/her not having access to the facility's front door, he attempted three (3) times to call the facility due to no one being with the resident to open the front door, but no staff would answer the phone. During an interview with the Director of Nursing (DON) on 08/11/2023 at 5:00 PM, she stated she did not know the process for dialysis residents but would assume the staff would get the resident up in the morning, give him/her a snack, and have the resident wait in his/her room for transportation, but she really was not sure. She said a resident might sit up front, and if they did, there should be a staff member there to let the driver in. She stated if a resident was unresponsive, they should never have been placed in the lobby. The DON stated the phones should be answered when they rang, and the front door bell should be answered when it rang. She stated she expected them to be answered within a reasonable amount of time or as soon as a staff member could get to them. During an interview with the ED on 08/11/2023 at 5:33 PM, he stated if a resident was unresponsive while waiting for transportation to dialysis, he would expect the nurse on duty to assess the resident immediately and call the physician. The ED stated if the phone or doorbell was ringing during the night or at times when there was not a receptionist in the building, he would expect staff to answer them in a reasonable amount of time, and four (4) to six (6) rings would be reasonable.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for two (2) out of thirty-nine (39) sampled residents (Residents #12 and Resident #74). 1. On the 06/11/2023 Standard Extended/Recertification/ Abbreviated Survey, Immediate Jeopardy was identified in the area of 42 CFR 483.25 Quality of Care ( F689). The State Survey Agency (SSA) exited the facility with Immediate Jeopardy (IJ) onging. The SSA concluded the first (1st) revisit, to remove the IJ, on 06/29/2023 and the facility had implemented corrective actions to remove the IJ, prior to the SSA exit. On 08/11/2023, the SSA concluded the Abbreviated Survey and found continued non-compliance related to complaint number, KY #39861 with Resident #74, in the area of F689. The complaint was identified as Immediate Jeopardy; however, due to the facility's corrective actions with removal date of 06/29/2023, the scope and severity S/S was lowered to a D, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. On 06/19/2023 at approximately 7:33 PM, Resident #74 exited the facility's main entrance to the sidewalk without staff's knowledge. The facility was unaware of Resident #74's whereabouts for approximately two (2) minutes until staff member, Certified Nursing Assistant (CNA) #30 looked out the window through another resident's room, room [ROOM NUMBER], and discovered Resident #74 was located outside in his/her wheelchair wheeling down the sidewalk. Licensed Practical Nurse (LPN) #16 did not know if Resident #74 was allowed to go outside due to Resident #74's wander guard in place and his/her history of wandering; therefore, re-directed the resident. Review of the local weather for 06/19/2023 at 7:33 PM, per historical data, revealed the weather for that day had a low temperature of sixty-nine (69) degrees Fahrenheit with high temperature around seventy-nine (79) degrees Fahrenheit with clouds and mild humidity in the area. 2. On 04/16/2023 at approximately 5:30 PM, Resident #65 reported to staff that Resident #12 had cussed at him/her last night, on 04/15/2023 at approximately 7:00 PM, The resident stated that while setting up the activity table for snacks, Resident #12 demanded a snack and started cussing at him/her and was verbally aggressive; however, Resident #12 was not monitored for his/her fifteen-minute checks for his/her behaviors. The findings include: Review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, revealed the facility was to strive to make the environment as free from accident hazards as possible. Per policy review, resident safety and supervision and assistance to prevent accidents were facility-wide priorities, and the facility utilized an individualized, resident-centered approach for safety. Continued review revealed the interdisciplinary team (IDT) was to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review revealed the IDT was to target interventions to reduce individual residents' risks related to hazards in the environment, including adequate supervision and assistive devices. Additionally, policy review revealed interventions implemented reduced accident risks and hazards. Review of the facility policy titled, Increased Supervision, undated, revealed increased supervision referred to the supervision of residents by staff to prevent opportunities for altercations or situations for the resident to harm themselves or others. 1. Review of Resident #74's medical record revealed the facility admitted the resident on 08/29/2021, with diagnoses which included abnormal gait and mobility, cognitive communication deficit, Alcohol Abuse, Encephalopathy, Vascular Dementia with behavioral/psychotic disturbance and restlessness and agitation. Review of Resident #74's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. Review of Resident #74's Comprehensive Care Plan, dated 02/16/2022, revealed the facility assessed the resident as an elopement risk/wanderer related to, attempts to exit the facility to get fresh air outside. Review revealed the interventions included: to ensure staff distracted the resident from wandering by offering pleasant diversions and structured conversation; identify pattern of wandering purposeful, aimless, or escapist; offer the resident snacks and structured activities and a room alert bracelet to alert staff of unsupervised attempts to exit. Continued review of the resident's care plan revealed an intervention was initiated on 03/02/2022, for staff to ensure visual checks of the resident every fifteen (15) minutes. Review of Resident #74's Elopement Risk assessment dated [DATE] at 11:44 AM, revealed the resident was assessed with a history of actual elopement, wandering that placed the resident at significant risk of getting to a potentially dangerous place, outside of the facility, the resident had expressed the desire to leave, such as to go home, talked about going on a trip, attempted to pack belongings and the resident exhibited one or more emotional state or behavior that may result in exit-seeking behavior; therefore, resident had been assessed to be at risk for elopement. Review of the Nurse's Progress Note, dated 06/19/2023 at 07:40 PM, revealed Resident #74 eloped to the front parking lot of the facility at approximately 7:33 PM; Certified Nursing Assistant, (CNA) #31 approached the nurse shouting, Resident #74 was outside!!! The nurse Licensed Practical Nurse (LPN) #16 rushed to the front of the building to find CNA #31 assisting resident inside the building at 7:40 PM. Continued review of the Note revealed no alarms were going off at that time, and Resident #74 did not verbalize intentions of leaving. Review of Resident #74's Active Order Summary Report revealed a verbal order was initiated on 06/19/2023 at 7:45 PM for the resident to have one-on-one (1:1) direct supervision and the resident's every (q) fifteen (15) minute checks were discontinued. Review of Resident #74's Supervision Check Flow Sheet revealed on 06/19/2023, (the day of the resident's elopement) the resident was on every (q) fifteen-minute (15) checks. The last documented check was at 7:30 PM and a new supervision flow sheet was initiated on 06/19/2023 at 7:45 PM (after resident elopement)for one-on-one (1:1) supervision. Review of the Long-Term Care Self-Report Incident Investigation Form,dated 06/23/2023, revealed Resident #74 exited the building's front door to the sidewalk. The alarm activated and functioned properly. Per review, it was concluded the resident wanted to go out with the smokers and the nurse, Licensed Practical Nurse (LPN) #16 stated she would need to check to see if the resident could go outside due to the resident wearing a wander guard. Continued review of the investigation revealed witnesses stated the resident became upset, left the area where he/she was talking to the nurse and then egressed the front lobby door. The investigation revealed Certified Nursing Assistant (CNA) #31 saw the resident on the sidewalk leading from the front door and she immediately went to retrieve the resident. Upon getting to the front door, the alarm sounded. During an interview on 07/13/2023 at 10:11 AM, with Resident #74 while he/she was outside in the courtyard smoking area with other residents. Resident was not smoking yet conversing with other residents that were smoking. Staff monitors were observed providing supervision of those residents. Resident #30 was in their wheelchair and stated he/she enjoyed being outside and recalled the day he/she left the building. Resident #30 stated, no one would let me go outside with the smokers, so I became upset. Resident #74 continued, he/she was pissed off and went to the front door and kicked it open to go outside. Resident stated, I know how to get out the doors. In addition, Resident #74 stated there were times he/she wanted to leave the facility and go see his/her son, but could not get out. During an interview on 07/17/2023 at 3:40 PM, with Certified Nursing Assistant (CNA) #31, she stated she was familiar with Resident #74. CNA #31 stated on 06/19/2023, she was working the east hall and had not provided care for Resident #74; however, she had seen him/her and spoken to the resident that day and observed no change in his/her behavior/attitude. She stated the resident was not mad and did not appear to be exit seeking on that day. CNA #31 stated the last time she saw the resident, it was on the west hall, smoking door area. The residents were lined up to go smoke on their smoking break, including Resident #74. CNA #31 stated she heard Resident #74 request to go outside at approximately 7:30 PM with the smokers, but the nurse (LPN #16) stated Resident #74 had a wander guard bracelet on and was not sure if resident was care planned to go outside. LPN #16 told Resident #74 to hold on until she could check and find out. CNA #31 stated that during this time the smoking doors were opened at 7:30 PM and CNA #31 went back to the east hall to pick up resident trays, at approximately 7:33 PM. Per the interview, the CNA stated she went to the Resident's room [ROOM NUMBER], and glanced out the window and saw Resident #74 on the sidewalk in front of the facility unsupervised, just rolling down the sidewalk in his/her wheelchair. CNA #31 added, alarms were going off on both, east and west units, as well as the front entrance exit. CNA #31 stated when she got to Resident #74 outside the front entrance, he/she was excited and informed that he/she was getting fresh air, resident was laughing and saying, I was almost out of here, I was gone. CNA #31 stated she had to encourage the resident to come back in. CNA #31 further stated within thirty (30) minutes management was in the facility to investigate, audit, interview and provide education related to elopement. During an interview on 07/17/2023 at 4:09 PM with Licensed Practical Nurse (LPN) #16, she stated she was an Agency Nurse, worked only a few times at the facility prior to 06/19/2023, and it was her first time to care for Resident #74. LPN #16 recalled at approximately 7:00 PM, she provided Resident #74's evening medication in front of the nursing station and performed his/her fifteen-minute supervision check due to resident's behaviors; however, at that time LPN #16 was not aware Resident #74 had a history of wandering and/or attempts of elopement. LPN #16 stated staff alerted her that Resident #74 attempted to go outside with the smokers, but added should could not go out with the resident as she was passing out medications. Further, she stated she was not certain the resident could go outside with his/her wander guard bracelet. LPN #16 stated the resident did not seem upset and/or distressed, remained at the nursing station; however, as she went into another resident room for medication pass and back out in the hallway, CNA #31 came running down the hall saying Resident #74 ran off and she did not hear an alarm, nor the door alarm for the smokers. In a continued interview with Licensed Practical Nurse (LPN) #16, on 07/17/2023 at 4:09 PM, she stated it was approximately five (5) minutes give or take since she had laid eyes on Resident #74. LPN #16 stated Resident #74 knew he/she could hold the door for seconds to release and unlock. LPN #16 revealed as she approached the front door to secure and ensure Resident #74's safety, resident was with CNA #31. LPN #16 stated she was informed afterwards resident was allowed to go outside with the smokers. LPN #16 stated resident's safety was a priority; however, Resident #74 was put in danger by him/her having access to exit the facility so easily and in such a high trafficked area, leading to the main road; resident could have gotten hurt, flipped his/her wheelchair on the pavement, or even worse, get hit by a car in the parking lot with a horrible outcome. LPN #16 stated, although Resident #74 was put on one-on-one supervision afterwards, she felt the resident should have been on one-on-one direct supervision, given her not knowing Resident #74's elopement/wandering history. In addition, LPN #16 stated the facility did not communicate, provide the education nor information that was necessary to provide a safe environment and appropriate care to residents with these types of behaviors, she felt the facility failed her and Resident #74. During an interview on 07/17/2023 at 4:10 PM, with Maintenance Director, he stated he worked at the facility since 2018, and was aware of a few facility elopements in the past year. The Maintenance Director stated that with Resident #74's elopement that occurred on 06/19/2023, the resident physically kicked the door and broke the hinge. The Maintenance Director stated Resident #74 had a certain mood in behaviors and enjoyed being outside. If the Resident wanted to go outside, he/she would do whatever it took to get outside, such as he/she did on this occasion. The Maintenance Director stated once a week he would check door alarms, the wander guard bracelets and expiration dates, and now since the incident he was checking daily. Further, he stated anyone was able to hold the door for fifteen (15) seconds, and the door would release the magnetic lock, per Fire Marshall regulation. Per the interview, the Maintenance Director stated since the elopement of Resident #74, door monitors were in place 24/7, daily/nightly and education with mock elopement drills were completed. He stated the facility purchased a new system, called Freedom nurse call system that would be initiated within the next few weeks, and would be tied into the security system that would provide more features; louder alarms at all exit doors and nurses' stations. He added, the new system would have speakers at each hallway to make all staff aware of the exact designation, when the alarm was initiated. In addition, the facility added exit stoppers immediately after resident elopement; screamers (chirper) were placed at all exit entries. Additionally, he stated staff must have a key to turn it off and must be reset; management and maintenance would keep a key on them and one secured and placed at each nurse's station. Additionally,the Maintenance Director stated the new improved alarm system was necessary to ensure the residents safety. During an interview on 07/18/2023 at 4:20 PM with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), stated they both received a call at approximately 7:30 PM on 06/19/2023, from the Executive Director (ED) via a three-way phone conversation to alert of Resident #74's elopement. The stated they immediately came to the facility and started an investigation. Also, the Maintenance Director was notified and came to assist with the elopement investigation, on 06/19/2023. The DON stated Resident #74 was not exhibiting any signs that might have indicated the resident was at risk for elopement. Per the interview, the ADON and DON stated they reviewed the the facility's investigation and determined Resident #74 had a history of exit seeking behaviors, and was angry and upset when he/she did not get their way to go outside. The ADON stated Resident #74 returned to the facility unharmed and safe, but just wanted to go outside. The DON and ADON stated Resident #74 was cognitive enough to hold the door and it released; however, the facility was continuing to review and educate all staff on Elopement with QAPI, and maintenance would continue to monitor/audit all exit doors with elopement drills, now daily. Management ensured all resident elopement binders were to be checked and updated daily; review and discuss residents at risk and ensure those residents were care planned appropriately and review/discuss daily in the morning meeting and weekly in QAPI with the Maintenance Director, and Staff Development Coordinator (SDC) involvement. DON stated education had been initiated and enforced daily, beginning the day of Resident #74's elopement on 06/19/2023, with continued education related to elopement and resident safety. During an interview on 07/18/2023 at 4:40 PM with the ED, he stated he was aware of Resident #74's elopement on 06/19/2023, and it was reported as an allegation to the State Survey Agency (SSA) out of abundance of caution as the facility was required to report within the required time frame and investigation was initiated with Resident #74 went out the front door to get fresh air and was in no danger at any time. Resident #74 had a history of going outside with other residents and staff during scheduled breaks. In addition, addressing the front door alarm and the door alarm to the smoking area sounding identical-the facility was placing a new door alarm system/wander guard system as the current system was unable to be updated. Further, he stated the resident would remain on 1:1 supervision until the doors were replaced to decrease any risk of residents going out of the facility unsupervised. ED further stated the facility did not substantiate that an actual elopement occurred as resident denied any desire to leave the facility, but only wanted to go outside and was upset as the nurse did not allow him/her to go outside. Additionally, a schedule was developed to allow Resident #74 the opportunity to go outside at scheduled times as desired with supervision of staff. In addition, he would expect his staff to notify him the DON/ADON immediately if a resident was exit seeking and/or eloped. 2 a) Review of Resident #65's Medical Record revealed the facility had admitted the resident on 01/04/2023, with diagnoses which included Spina Bifida with Hydrocephalus, and adjustment disorder with depressed mood. Review of Resident #65's Quarterly MDS dated [DATE], revealed the facility had assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Review of Resident #65's Progress Notes, dated 04/16/2023 at 5:29 PM, revealed RN #4 was in Resident #65's room assessing his/her roommate and Resident #65 stated that last night he/she was setting up a snack table for movie night and another resident (Resident #12), demanded a snack and started cussing at him/her and being verbally aggressive. Resident #65 verbalized he/she did not feel safe around this resident. Review of Resident #65's Provider Summary Progress Note, dated 04/17/2023 at 4:00 PM, revealed Resident #65 visit encounter due to an abuse allegation; R#65 reported verbal abuse by another resident (R#12). Resident #65 reported, I was putting out snacks for movie night, Resident #12 came up and started yelling give me a snack. R#65 told him/her to hold on just a minute and he/she would give R#65 a snack when he/she finished setting up. R#12 yelled give me a snack again. Resident #65 informed R#12 to hold on a second, Resident #12 called him/her a bitch and snatched a bag of popcorn out of his/her hands. Resident #12 denied the allegation. However, R#65 reported he/she is scared of other resident, but did not want to move rooms. During an interview on 07/19/2023 at 8:30 AM, Resident #65 stated he/she got along with other residents for the most part. Resident #65 stated he/she was having a movie night and on this evening, Resident #12 came into the activities room unsupervised about 5:30 PM. Resident #65 stated he/she continued setting up the snack table when Resident #12 came in the activity room in his/her wheelchair and approached Resident #65 abruptly and aggressively stating, give me a snack. Resident #65 stated he/she informed Resident #12 he/she would provide him/her a snack as soon as he/she got the snacks ready, but informed Resident #12 that he/she would have to stay and watch the movie. Resident #65 stated Resident #12 then stated to give him/her a fucking snack and grabbed one away from him/her. Per the interview, Resident #65 stated there was no one else in the room to assist or supervise the situation, as the Activities Director had already left for the day, and no staff were monitoring. Resident #65 stated he/she was shocked yet frightened of Resident #12's behavior. Resident #65, in an interview on 07/19/2023 at 8:30 AM, stated he/she believed Resident #12 called him/her a bitch under his/her breath when he/she snatched the snack from him/her and wheeled off, out of the room hostile and angry. Resident #65 stated he/she was thankful the situation ended the way it did as he/she could have been physically hurt due to Resident #12 being angry and aggressive towards him/her. Further, the resident stated he/she did not alert staff of the incident until the next day. 2 b) Review of Resident #12's Medical Record revealed the facility admitted resident on 10/21/2016, with diagnoses which included, but not limited to hemiplegia and hemiparesis following Cerebral Vascular Infarction (CVA), Aphasia, Major Depressive Disorder, Mood Disorder due to known psychological condition with depressive features, Vascular Dementia with moderate agitation, Behavioral and Psychotic Disturbance, and Anxiety. Review of Resident #12's Quarterly MDS dated [DATE], revealed the facility had assessed the resident as having a BIMS score of ten (10) out of fifteen (15) which indicated the resident demonstrated moderate cognitive impairment. Continued review of Resident #12's Activities of Daily Living (ADL) assessment revealed he/she required supervision of one staff member for locomotion in wheelchair on/off unit. Review of Resident #12's Social Service Progress Note, dated 04/17/2023 at 3:24 PM, revealed the Social Service Director (SSD) met with Resident #12 who nursing reported had inappropriate behaviors on Friday, 04/16/2023 per two (2) other residents, Resident #65 and another unknown Resident. Resident #12 reported, listen I said I was sorry to one of'em but the other one is a fucking bitch and I told him/her that he/she was. During an interview with Resident #12, on 07/20/2023 at 10:02 AM, the resident stated he/she did not recall any verbal altercation and/or verbal abuse towards Resident #65, and/or any other resident. Throughout the interview with Resident #12, he/she consistently and repeatedly would randomly state the word, fuck. During interview on 07/18/2023 at 11:10 AM, with the Activities Director, he stated residents could schedule their own activities, such as a movie night and prayer services. He stated Resident #65 approached him with request for a movie night. Per calendar review for April 2023 movie night was on Friday nights and Resident #65 requested for 04/16/2023 at 7:00 PM. The Activities Director stated he would leave the facility around 4:00 PM to 5:00 PM daily. At that time, he did not have a designated staff in house to monitor/assist with residents during after hours, to monitor movie night for the residents. The Activities Director stated nurses/staff were responsible to assist residents during activities and events, such as movie night to ensure their safety. He added on occasion the facility would provide snacks, such as popcorn and he believed Resident #65 had attempted to tell Resident #12, the popcorn was for those residents that were planned to stay and watch the movie; however, Resident #12 was not going to have it that way, so he/she acted out towards Resident #65. He further stated Resident #12 had a tendency to get angry with periods of agitation and required redirection. The Activities Director further stated that not having staff to supervise the residents put them at risk with a potential harmful outcome to include the resident's choking on popcorn and/or any of the other snacks that were provided and resident altercations with unwarranted behaviors. During an interview on 07/24/2023 at 2:44 PM with Registered Nurse (RN) #4, she stated she was the weekend supervisor, familiar with both Resident #65 and Resident #12. Per the interview, she stated the resident reported to her on 04/16/2023 at approximately 5:30 PM, Resident #12 was cussing at him/her last night. Per the interview, she stated the resident was setting up a snack table for movie night and another resident, Resident #12, demanded a snack and started cussing at him/her and being verbally aggressive. Resident #65 verbalized he/she was very uncomfortable around Resident #12 and did not feel safe around this resident. During an interview on 07/18/2023 at 1:10 PM with the Assistant Director of Nursing (ADON), she stated Resident #12, wanted what he/she wanted, when he/she wanted, and had difficulty choosing the appropriate verbiage/words. ADON stated the altercation between Resident #12 and Resident #65 occurred during movie night when Resident #12 went to get popcorn but did not want to stay and watch the movie. She stated Resident #65 did not want to give the popcorn if the residents did not watch the movie. Further, she stated management should have monitored/rounded to ensure the residents were provided supervision to prevent negative outcomes and altercations for the safety of all residents. During an interview on 08/03/2023 at 10:41 AM with ARNP, stated she was very familiar with Resident #12 and stated he/she had behavioral tendencies towards staff and residents, mostly verbal. The ARNP stated Resident #65 had much improved with medication adjustment; however, he/she still required to be monitored for those behavior tendencies with potential outburst. ARNP stated staff and management must ensure the appropriate supervision of all residents. *******The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident was placed on one-to-one on 06/19/2023. 2. All residents assessed to wander or for elopement were at risk. The facility had 10 residents assessed an in the elopement binder. The Care plans of the residents were reviewed with Resident #74's care plan being updated to include supervision. 3. The facility completed elopement drills for the following dates: 04/22/2022 on each shift, 04/23/2022 on each shift, 04/24/2022, 04/28/2022, 05/05/2022, 05/12/2022, 05/20/2022, 06/08/2022, 06/12/2023, and 06/13/2023. Elopement drills, done on varying shifts, would continue multiple times weekly. The Maintenance Director or nursing staff would perform the drills until the Immediate Jeopardy (IJ) was removed. The drills would continue monthly thereafter. Audit Tools #2 and #3 would be used for these drills. 4. QAPI was held on 06/28/2023 with the QAPI Committee. *****The State Survey Agency (SSA) validated removal of the Immediate Jeopardy on 06/29/2023 as follows: 1.Observation for Resident #74 revealed the resident continued to have one-on-one 1:1. 2. All residents assessed to wander or for elopement were at risk. The facility had 10 residents assessed an in the elopement binder. The Care plans of the residents were reviewed with Resident #74's care plan being updated to include supervision. 3. Review of the facility's elopement drills binder revealed the facility conducted elopement drills as alleged on each shift of 04/22/2023, 04/23/2022, and 04/24/2022; once per day 04/28/2022, 05/05/2022, 05/12/2022, 06/08/2022, and 06/23/2022. Further review revealed the facility conducted elopement drills each month from 07/2022 through 06/20/2023; starting 06/20/2023, the facility conducted at least two (2) drills every day through 06/28/2023. During an interview on 07/17/2023 at 4:10 PM, with the Maintenance Director, he stated he worked at the facility since 2018, and was aware of a few facility elopements in the past year. The Maintenance Director stated when the alarm took place, an annunciator panel was placed on every nursing unit and different areas in the building, whether it's an emergency or not, the system would egress. The annunciator would have multiple lights going off and provide the designated area. Staff must clear the code with the same exit that triggered, and everyone was responsible to check the alarm system, all hands-on deck; check inside and outside the perimeter and discover why the alarm was going off. Maintenance Director stated normal procedure was to audit/check doors and water temps daily. He informed the State Survey Agent (SSA) since the elopement of Resident #74, door monitors were in place 24/7, daily/nightly education with mock elopement drills and most importantly, the facility purchased a new system, Freedom nurse call system that would be initiated within the next few weeks, and would be tied into the security system that would provide more features; louder alarms at all exit doors and nurses' stations. He added, the new system would have speakers at each hallway to make all staff aware of the exact designation, when alarm initiated. In addition, the facility added exit stoppers immediately after resident elopement; screamers (chirper) were placed at all exit entries, the stoppers are extremely loud. Additionally, staff must have a key to turn it off and must be reset; management and maintenance would keep a key on them and one secured and placed at each nurse's station. Additionally, Maintenance Director stated the new improved alarm system was necessary to ensure residents with these types of behaviors their safety. 4. Review of the QAPI Committee minutes, dated 06/28/2023, revealed the ADON, Maintenance Director, SSD, Medical Director, UM #1, SDC, DON and ED #2 were present at the meeting. Further review revealed the team discussed the elopement management plan, adding a new audit of Wander Guard bracelets, to be completed daily for two (2) weeks, three (3) times per week for four (4) weeks, weekly for four (4) weeks, and monthly for four (4) months.

Based on observation, interview, record review, review of the facility's policies and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for four (4) of twenty-four (24) sampled residents (Residents #160, #310, #359, and #161). 1. Resident #160 expressed to staff his/her desire to be discharged home and he/she was anxious about his/her upcoming court hearing. The resident reported his/her concerns to staff on [DATE]; the week of [DATE], and on [DATE]; however, the facility failed to develop the resident's individualized person-centered care plan to include adequate supervision and monitoring. Therefore, on [DATE], the resident exited his/her window, climbed on a table with a chair stacked on top of the table and climbed across the facility's six (6) foot fence. The facility was unaware of the resident's whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes. 2. Review of Resident #310's Comprehensive Care Plan dated [DATE], revealed the facility care planned the resident for impaired lung function related to Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed interventions which included to encourage the resident to wear his/her nasal cannula when he/she removed it. Further review revealed however, the facility failed to develop Resident #310's care plan with an intervention for staff to ensure the resident's oxygen cannula stayed on as ordered. As a result, the resident experienced periods of confusion on [DATE] and [DATE]. 3. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed the resident was care planned for (1) or two (2) staff to turn and reposition him/her in bed as needed. However, the facility failed to develop the resident's care plan related to his/her assessed needs of requiring the assistance of two (2) or more staff to assist with bed mobility and transfers. Additionally, the facility failed to ensure the resident's care plan was developed to include interventions to prevent skin tears during his/her wound dressing changes. This caused the resident to experience preventable skin tears on his/her right, posterior, lateral thigh, and of the right, lower knee, which occurred during his/her wound dressing changes, and a skin tear occurred on his/her upper arm, which occurred during a one (1) person assist. 4. The facility admitted Resident #161 on [DATE] and failed to assess the resident for his/her smoking safety upon admission. On [DATE], the resident exited the facility to smoke independently and fell out of his/her wheelchair, causing him/her to sustain a small abrasion to the resident's left below the knee amputation. The facility failed to develop the resident's care plan to include the need for assisted and supervised smoking. The facility's failure to have an effective system in place to ensure the residents' Comprehensive Care Plans were developed and/or implemented with a comprehensive person-centered care plan for each resident, consistent with the residents' rights has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F689 at a S/S of a J, along with Substandard Quality of Care (SQC). The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and is ongoing. The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised [DATE], revealed the Interdisciplinary Team (IDT) was to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility policy titled, Comprehensive Care Plan, dated [DATE], revealed the facility was expected to develop a person-centered care plan for each resident to enable the resident to live with dignity. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised [DATE], revealed the comprehensive, person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and reflected currently recognized standards of practice for problem areas and conditions. Continued review revealed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 1. Review of Resident #160's closed medical record revealed the facility admitted him/her on [DATE], with diagnoses of Type II Diabetes Mellitus, Nontraumatic Intracerebral Hemorrhage, and Heart Failure. Review of Resident #160's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed him/her as having a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating he/she had moderately impaired cognition. Review of the resident's Admission History and Physical Hospital Record, dated [DATE], revealed the resident had a history of attention and memory deficits. Further review revealed the resident gave convoluted details of his/her history that had to do with the resident's recent release from jail and had been living in the wild. Further review of the hospital record revealed the resident was diagnosed with Encephalopathy (a form of brain damage) with motor planning and higher cognitive deficits over and above previous baseline. Review of a Nurse's progress note dated [DATE] at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. Review of Resident #160's Care Plan, dated [DATE], revealed the facility assessed the resident for impaired cognitive function/dementia or impaired thought processes related to the resident's Brief Interview of Mental Status (BIMS) score less than 13. Review revealed the interventions included: administration of medications as ordered, monitor/document side effects and effectiveness; staff were to encourage the resident to verbalize feelings and fears; approach resident in a calm; friendly, non-rushed manner; use the resident's preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions - turn off the television, radio, close his/her door; and the resident understands consistent, simple, directive sentences; provide the resident with necessary cues. Additionally, staff were to stop and return if agitated. Further review revealed however, there was no documentation to support the interdisciplinary team (IDT) targeted interventions to reduce individual risks related to accidents and incidents, to include adequate supervision and monitoring of the resident's environment for his/her safety, as per the facility's policy. Review of the facility's investigation initiated on [DATE], revealed Resident #160 had exited the facility through his/her window, into the courtyard and over the fence. Continued review revealed Resident #160 was last seen by staff on [DATE] at 10:30 PM, when his/her nurse administered his/her medications. Per review, Resident #160 was reported as missing on [DATE] at approximately 12:30 AM. Further review revealed staff notified the administrative team, and the police. Additional review revealed on [DATE] at 11:15 AM, the facility received a call from a local shelter who reported Resident #160 was located. Staff were unaware of the resident's whereabouts for approximately one (1) day, twelve (12) hours, and forty-five (45) minutes. Review of a Nurse's Progress Note dated [DATE] at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. In an interview on [DATE] at 11:16 AM, Certified Nursing Assistant (CNA) #19 stated Resident #160 had reported to her he/she wanted to get his/her own place when he/she was better. The CNA stated Resident #160 had been anxious about an upcoming court hearing. CNA #19 further stated she did not report this information to anyone. Review of the former Social Service Director (SSD) typed statement from the investigation, dated [DATE], revealed the SSD approached the resident the week of [DATE]-[DATE], she added she could not recall the exact date. Per review of the statement, the resident voiced questions about his/her discharge and wanted to know how much more time he/she had in the facility. Further review revealed the resident asked if he/she could be discharged to a halfway house. Review of the witness statement for the former Director of Nursing (DON), undated, revealed she received a call from Licensed Practical Nurse (LPN) #1, on [DATE] at 12:33 AM, and she informed her the resident was missing and she stated, I think he/she went out the window. Further review of the statement revealed the former DON responded by stating, OMG we were just talking about discharge. In an interview on [DATE] at 4:21 PM, the former Minimum Data Set (MDS) Nurse stated staff communicated with other staff and discussed any care plans that needed to be initiated or revised. She further stated if a new intervention had been put into place, the care plan would have been completed in the morning meeting. In an interview on [DATE] at 10:42 AM, the new MDS Nurse stated she was new at the facility having only started on [DATE]. She stated in general, if a resident had a BIMS score of twelve (12), she would have initiated a care plan related to any cognitive changes the resident might have. In an interview on [DATE] at 6:35 PM, the Assistant Director of Nursing (ADON), stated she completed the admission assessment for Resident #160. The ADON stated she recalled Resident #160 was not exhibiting any symptoms that might have indicated the resident was at risk for wandering. However, review of the staffs witnesses statements revealed the resident was anxious and discussed with staff his/her concerns with his/her court hearing and wanted to be discharged to return home on [DATE]; sometime within the week of [DATE]; and the day before he/she went missing on [DATE]. She stated residents' care plans were created by the interdisciplinary team (IDT); however, any nurse was able to update a resident's care plan as needed. The ADON further stated if Resident #160 had been at risk for wandering, his/her care plan would have been updated with increased supervision. 2 a). Review of Resident #310's closed Admission Record revealed the facility admitted the resident on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Bipolar Disorder, and Schizoaffective Disorder. Review of the facility document, Provisional Report of Death, revealed Resident #310 died on [DATE]. Review of Resident #310's Admission MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #310's Comprehensive Care Plan dated [DATE], revealed the facility care planned the resident for impaired lung function related to Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed interventions which included to encourage the resident to wear his/her nasal cannula when he/she removed it. Further review revealed however, the facility failed to develop Resident #310's care plan with interventions that directed staff to ensure the resident's oxygen cannula stayed on as ordered. Review of Resident #310's Treatment Administration Record (TAR) dated ,d+[DATE], revealed the task for ensuring the resident's oxygen cannula was in place was only scheduled for once per shift, for a total of three (3) times in each twenty-four (24) hour period. Review of the facility's investigation into sexual abuse allegations made by Resident #310, on [DATE], revealed the resident removed his/her supplemental oxygen, became hypoxic and confused. Continued review revealed Resident #310 was found by staff in his/her bed, naked, and covered in feces and reported staff had raped him/her. Further review revealed when staff replaced the supplemental oxygen, Resident #310 recanted his/her statement about being sexually abused. In an interview on [DATE] at 3:51 PM, State Guardian #2 stated her expectation for the care of a resident under State Guardianship was for facility staff to ensure care was provided according to Physician' orders and the resident's care plan. In an interview on [DATE] at 2:25 PM, CNA #6 stated she remembered Resident #310 removed his/her oxygen frequently, especially when moving from the oxygen concentrator in his/her room to an oxygen tank for mobility around the facility. She stated she did her best to monitor when Resident #310 left his/her room so that she could ensure the resident had a nasal cannula connected to a full oxygen tank. CNA #6 stated however, if she did not see Resident #310 leave his/her room, there was not a specified time frame specified in the resident's care plan for when staff should ensure the resident's oxygen was in place. She further stated the importance of residents' care plans was to make sure each resident received the care they needed. In an interview on [DATE] at 2:28 PM, CNA #23 stated Resident #310 had often taken his/her oxygen off; however, had been very social and frequently out in the hallway, where staff were able to remind the resident to put his/her oxygen cannula back on when it was not in place. She stated staff did not have a specified interval for ensuring Resident #310's oxygen cannula was in place. She further stated care plan interventions needed to be implemented to ensure each resident could have the care they needed. In an interview on [DATE] at 9:33 PM, LPN #1 stated she recalled Resident #310 removing his/her oxygen while self-propelling himself/herself throughout the facility. She stated she did not follow a schedule for checking Resident #310's nasal cannula to ensure it was in place. LPN #1 stated therefore, she would not be able to determine how long Resident #310 had been without his/her prescribed supplemental oxygen at any given time, such as on the day of the incident. In an interview on [DATE] at 1:32 PM, RN #2 stated Resident #310 was noncompliant with wearing his/her oxygen cannula, so staff assisted him/her in replacing the nasal cannula whenever they noticed he/she had removed it. She further stated there was not a specified time frame for checking the nasal cannula to ensure Resident #310 was wearing it as ordered. In an interview on [DATE] at 9:54 AM, LPN #12/Unit Manager stated Resident #310 was noncompliant with wearing his/her oxygen nasal cannula as prescribed. She stated it was her expectation the care plan would include monitoring the resident frequently enough to prevent hypoxia. 2 b). Review of the facility's investigation into a second sexual abuse allegation involving Resident #310 dated [DATE], revealed the resident had removed his/her oxygen again, became hypoxic, confused, smeared feces on his/her body, and rolled around in the hallway naked. Continued review revealed CNA #10 took Resident #310 into the shower room alone, not following the Care in Pairs, intervention to give the resident a shower, at which time, the resident said, She's raping me. Further review revealed that once Resident #310's oxygen was replaced and his/her oxygenation levels returned to normal, the resident recanted his/her statement. Review of CNA #10's written statement from the investigation revealed she took Resident #310 into the shower room to clean the feces off the resident's body; however, failed to take another staff member with her. Further review revealed that when Resident #310 stated, She's raping me, CNA #10 took the resident back to his/her room and reported the allegation. Review of Resident #310's care plan dated [DATE] revealed Care in Pairs was added as an intervention on [DATE], after the first incident. Further review revealed the facility added an intervention on [DATE] that re-iterated that staff should perform Care in Pairs. Telephone interview was attempted with CNA #10 on [DATE] at 1:25 PM and [DATE] at 3:36 PM; however, a message was received stating the phone number was not in service. In an interview on [DATE] at 1:52 PM, the Social Services Director (SSD) stated the IDT discussed CNA #10 going into the shower room alone with Resident #310 even though the care plan specified she should have performed the task with another staff member as care planned. She further stated she believed CNA #10 received education about following the care plan. In an interview on [DATE] at 3:52 PM, the former Minimum Data Set (MDS) Coordinator stated that reminding Resident #310 to wear his/her oxygen cannula once per shift would not have been a sufficient intervention due to the resident's impaired cognition. She stated an appropriate, resident-specific intervention was to specify more frequent checks of Resident #310's oxygen, such as every two (2) hours. The former MDS Coordinator stated her process for care plan development was to review the care areas to ensure the care plan developed addressed all relevant disciplines for a resident's care. Additionally, she stated that all IDT members were able to modify residents' care plans when they identified a need for a different or more specific intervention. In an interview on [DATE] at 3:34 PM, the former DON stated that she believed the care plan which had been developed for maintaining Resident #310's oxygenation had been appropriate because the resident was out in the common areas of the unit where he/she could be easily monitored without requiring a specified time frame for monitoring. She stated on [DATE] and [DATE], Resident #310 removed the nasal cannula as soon as staff replaced it; and she did not believe there had been another intervention the facility could have implemented that would have been effective. In addition, she stated care plans were an important communication tool to ensure residents received the individualized care they required. In an interview on [DATE] at 11:54 AM, the ADON stated she was aware Resident #310 frequently removed his/her oxygen nasal cannula. The ADON stated she expected residents requiring supplemental oxygen to have that care planned. She further stated she expected staff to encourage a resident who required supplemental oxygen therapy to wear their nasal cannulas as care planned and prescribed. In an interview on [DATE] 11:31 AM, the DON stated that she was acting as the Unit Manager at the time of Resident #310's admission to the facility. She stated she did not recall what the IDT determined the root cause of Resident #310's increased confusion. The DON further stated Resident #310's care plan interventions included providing Care in Pairs and encouraging the resident to wear his/her nasal cannula. 3. Review of Resident #359's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses of Type II Diabetes, Chronic Kidney Disease, Stage Four (4), and Acquired Absence of Left Leg Above Knee. Review of Resident #359's Admission MDS assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was cognitively intact. Continued MDS review revealed the facility assessed Resident #359 to require assistance of two (2) or more people with his/her bed mobility and transfers. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed interventions included: using a pressure reducing mattress; turning and repositioning; assistance with bed mobility by using one (1) or two (2) staff to turn and reposition his/her in bed as needed. However, the facility failed to develop the resident's care plan related to his/her assessed needs of requiring the assistance of two (2) or more staff to assist with bed mobility and transfers. Additionally, the facility failed to ensure the resident's care plan was developed to include interventions to prevent skin tears during his/her wound dressing changes. Review of the Wound Physician's Progress note dated [DATE], revealed Resident #359 had been treated for five (5) wounds/skin tears. Per review the sites were noted as: Site one (1) a skin tear to the right, posterior thigh and was resolved; Site two (2) was a skin tear to the right shin; Site three (3) a Stage two (2) pressure wound to the right buttock. Continued review revealed Site four (4) was noted as a skin tear wound to the right, posterior, lateral thigh, and Site five (5) a skin tear of the right, lower knee. Per review of the Wound Care Nurse's written statement wound sites 1, 2, and 3 had all been present at the time of Resident #359's admission. Further review of the documentation revealed the skin tears listed as sites 4 and 5 resulted from dressing changes being performed of wound sites 1 and 2. Review of Resident #359's Skin Observation Tool, dated on [DATE] revealed a new skin tear to left upper arm/antecubital. Review of Nursing Progress Notes, dated [DATE] at 9:37 PM, revealed the skin tear to the resident's left upper arm was documented to have occurred. Continued review of the Note revealed no indication or description of how the skin tear occurred. Further review revealed the Nurse Practitioner was notified, and orders were received for care to the new wound. Interview on [DATE] at 3:41 PM, revealed CNA #9 stated he pulled Resident #359 up in bed without assistance of another staff person. He stated pulling Resident #359 up alone resulted in the resident getting a skin tear on his/her arm. He further stated he felt he could pull the resident up on his own and did not need another staff member to assist him. Interview on [DATE] at 8:35 PM, revealed Registered Nurse (RN) #2 stated she remembered an incident where CNA #9 told her he pulled Resident #359 up in bed by himself. She stated she recalled the CNA reported Resident #359 sustained a skin tear to his/her upper arm. Interview on [DATE] at 6:40 PM, revealed RN #2 stated Resident #359 had skin tears, and there were things she would have done to prevent skin tears, such as be gentle with the resident. She stated however, she was unsure whether there were interventions to prevent skin tears on Resident #359's care plan or not. RN #2 stated she would have put an intervention on Resident #359's care plan for staff to be gentle with the resident's skin so the CNAs would know they needed to be. She further stated she was unaware Resident #359's skin was fragile until [DATE], when the resident sustained the skin tear from the CNA pulling him/her up in bed by himself. Interview with RN #4/Wound Care Nurse/Weekend Unit Manager, on [DATE] at 10:40 AM, she stated that it would have helped prevent the resident's risk of skin tears if the person-centered care plan had been developed for the resident. Interview on [DATE] at 3:56 PM, revealed the former MDS Coordinator stated care plans should be specific to residents. She stated a resident with skin tears should have specific interventions for preventing skin tears such as prevention of skin tears when removing bandages. The former MDS Coordinator reviewed Resident #359's care plan and stated she did not see interventions in place to prevent skin tears; however, she felt there should have been interventions in place since the resident was admitted with skin tears. She further stated she felt the interventions on Resident #359's care plan were not adequate and could have caused the resident to have a bad outcome. Interview on [DATE] at 5:42 PM, revealed the Director of Nursing (DON) stated she expected nursing staff to assess residents for all skin issues when the resident was admitted . She further stated skin must be included for Resident #359's plan of care to meet the facility's goal of providing person-centered care. Interview on [DATE] at 7:17 PM, revealed the Executive Director (ED) stated she expected her staff to develop person-centered care plans for the residents in her facility. She stated she wanted the culture to be all about them, for example, when they (the resident) wanted something and how they wanted it. The ED stated her expectation was that care plans included providing interventions for the skin issues of residents to keep them safe. She further stated her expectation was that extra precautions would be put in place to prevent skin tears for any resident with thin skin. In addition, the ED stated that information should have been included on the care plan for a resident with those needs. 4. Review of Resident #161's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Cognitive Communication Deficit, Left below the Knee Amputation and Bipolar Disorder. Review of the five (5) day MDS assessment dated [DATE], revealed the facility assessed Resident #161 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident's cognition was intact. Review of the Long-Term Care Self-Report Incident Investigation Form, initiated on [DATE], revealed Resident #161 exited the back door of the facility by pushing the egress bars until it released. Per the review, Resident #161 was in his/her wheelchair which he/she was able to self-propel. Continued review revealed the door alarm sounded on [DATE] at 9:40 PM, which alerted staff and staff responded. Certified Nursing Assistant (CNA) #26 located the resident outside of the facility, on the ground. Continued review revealed the wheels of the resident's wheelchair ran off the edge of the sidewalk, which caused the wheelchair to tilt, and the resident turned over. Continued review revealed Licensed Practical Nurse (LPN) #12 also responded and helped the CNA assist Resident #161 back into his/her wheelchair and back into the building. Review further revealed LPN #12 and observed an abrasion to his/her left stump (a residual limb). Review of the Nursing Progress Note documented as a Late Entry on [DATE] at 9:45 PM, by Licensed Practical Nurse (LPN) #12 revealed Resident #161 had been found outside an exit door. Per review of the Note, Resident #161 was assessed for injuries and a small abrasion was observed to the resident's left below the knee amputation (L BKA) area. Review of Resident #161's smoking assessment, dated [DATE], revealed the resident was assessed to require the use of a smoking apron and assessed to have supervision while smoking. Review of Resident #161's Comprehensive Care Plan dated [DATE] revealed the facility care planned the resident for a risk to exit seek related to his/her desire to smoke without supervision. However, the facility failed to assess the resident for his/her smoking safety upon admission to ensure his/her care plan was developed to indicate a need for assisted and supervised smoking. Review of a Social Service Progress Note, dated [DATE] at 1:02 PM, revealed the Social Worker had met with Resident #161 to review the facility's smoking policy. Continued review revealed Resident #161 verbalized understanding of the policy. In an interview on [DATE] at 9:14 AM, the Director of Nursing (DON) stated care plans were to be person-centered with the individual resident's needs in mind when developed. She stated she expected care plans to be developed and revised to meet the needs of each resident. In an interview on [DATE] at 6:42 PM, the Executive Director (ED) stated her expectation was for care plans to be resident-specific and developed to address all care areas impacting resident care. 46710 48266

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for three (3) of twenty-four (24) sampled residents (Residents #160, #161, and #359). 1. On 04/22/2022 at approximately 12:30 AM, Resident #160 exited the facility through his/her window without staff's knowledge. The facility was unaware of Resident #160's whereabouts until a local shelter notified staff by telephone on 04/23/2022 at 11:15 AM of the resident's location. The resident was last seen on 04/21/2022 at 10:30 PM by Licensed Practical Nurse (LPN) #13, who checked his/her blood sugar and administered insulin as ordered at that time. Review of the local weather for 04/22/2022, per historical data, showed a low temperature of fifty-nine (59) degrees Fahrenheit with high temperature around seventy-nine (79) degrees Fahrenheit with light rain showers in the area. 2. On 08/14/2022 at 9:40 PM, Resident #161 exited the back door of the facility and the alarm sounded, alerting staff. The resident was found on the ground where he/she had fallen out of his/her wheelchair to smoke independently. The facility failed to assess the resident for smoking safety and supervision when the resident was admitted on [DATE]. As a result, the resident sustained a small abrasion on his/her left below the knee amputation. 3. Resident #359 was pulled up in bed by only one (1) CNA which resulted in the resident sustaining a skin tear to his/her left upper arm. In addition, during wound care as the dressings were removed the adhesive resulted in Resident #359 sustaining two (2) additional skin tears. The facility's failure to have an effective system in place to ensure the residents' environment remained free of accident hazards and failed to ensure the residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/10/2023 and was determined to exist on 04/22/2022 in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F 656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F 689 at a S/S of a J, along with Substandard Quality of Care (SQC). The facility was notified of the Immediate Jeopardy (IJ) on 06/10/2023 and is ongoing. The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised July 2017, revealed the facility was to strive to make the environment as free from accident hazards as possible. Per policy review, resident safety and supervision and assistance to prevent accidents were facility-wide priorities, and the facility utilized an individualized, resident-centered approach for safety. Continued review revealed the interdisciplinary team (IDT) was to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review revealed the IDT was to target interventions to reduce individual residents' risks related to hazards in the environment, including adequate supervision and assistive devices. Additionally, policy review revealed interventions implemented reduced accident risks and hazards. Review of the facility policy titled, Increased Supervision, undated, revealed increased supervision referred to the supervision of residents by staff to prevent opportunities for altercations or situations for the resident to harm themselves or others. 1. Review of Resident #160's closed medical record revealed the facility admitted the resident on 03/10/2022, with diagnoses which included Partial Traumatic Amputation of right foot, Nontraumatic Intracerebral Hemorrhage, Diabetes Mellitus with Diabetic Neuropathy and Heart Failure. Review of the resident's Admission History and Physical Hospital Record, dated 02/01/2022, revealed the resident had a history of attention and memory deficits. Further review revealed the resident gave convoluted details of his/her history that had to do with the resident's recent release from jail and had been living in the wild. Further review of the hospital record revealed the resident was diagnosed with Encephalopathy (a form of brain damage) with motor planning and higher cognitive deficits over and above previous baseline. Review of a Nurse's Progress Note dated 03/20/2022 at 4:40 PM, revealed Resident #160 expressed to Registered Nurse (RN) #2 a desire to be discharged from the facility so he/she could go back home. Review of Resident #160's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated he/she had moderate cognitive impairment. Review of Resident #160's Care Plan, dated 03/25/2022, revealed the facility assessed the resident for impaired cognitive function/dementia or impaired thought processes related to the resident's Brief Interview of Mental Status (BIMS) score less than 13. Review revealed the interventions included: administration of medications as ordered, monitor/document safe effects and effectiveness; allow, encourage resident to verbalize feelings and fears; approach resident in a calm; friendly, non-rushed manner; use the resident's preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions - turn off the television, radio, close his/her door; and the resident understands consistent, simple, directive sentences; provide the resident with necessary cues. Additionally, staff were to stop and return if agitated. Further review revealed however, no documented evidence of interventions to increase Resident #160's supervision related to his/her verbally expressing the desire to go home on 03/20/2022. Review of the Long-Term Care Self-Report Incident Investigation Form, attachment to Section C, dated 04/22/2022, revealed Resident #160 exited the facility by circumventing the safety mechanism on the window by physically shoving the window up and bending the window stops to get out into the secured courtyard. Per review, it was determined Resident #160 stacked a table and chair from the courtyard next to the fence and the building, to crawl over the fence. The investigation revealed the resident was located on 04/23/2022 at approximately 11:15 AM at a local shelter. Continued review of the investigation noted all the windows in the facility were checked and in good order with the appropriate safety mechanisms in place. Review of the witness statement for Certified Nursing Assistant (CNA) #19, dated 04/22/2022, revealed the CNA gave her statement over the phone. Per review of the statement, the CNA reported the resident was anxious about an upcoming hearing. Review of the former Social Service Director (SSD) typed statement from the investigation, dated 04/22/2022, revealed the SSD approached the resident the week of 04/11/2022-04/14/2022, she added she could not recall the exact date. Per review of the statement, the resident voiced questions about his/her discharge and wanted to know how much more time he/she had in the facility. Further review revealed the resident asked if he/she could be discharged to a halfway house and the former Social Service Director explained to the resident he/she had rights; however, based on the resident's wounds, it would have been an unsafe discharge. Review of Licensed Practical Nurse (LPN) #13's witness statement from the investigation, dated 04/22/2022, revealed on 04/22/2022 at 10:30 PM, she checked the resident's blood sugar and gave his/her insulin. Continued review revealed she remained at the facility until 12:10 AM. Review of Licensed Practical Nurse (LPN) #14 witness statement from the investigation, dated 04/22/2022, revealed that at approximately midnight she came out of room [ROOM NUMBER] and was informed by the CNA (identity not indicated on the statement) that the resident was not in his/her room and could not be located. Continued review revealed she looked in the rooms on the unit, the bathrooms, and {through} all doors that were open for the resident. Further, she stated Licensed Practical Nurse (LPN) #1 was on the phone with the Executive Director (ED). She revealed she walked outside of the building to look for the resident. Continued review revealed LPN #14 was informed by a CNA (identity not indicated on the statement) that when the CNA looked on the other side of the fence, the CNA did not see the resident. Review of LPN #1's witness statement from the investigation, dated 04/22/2022, revealed a CNA (identity not indicated on the statement) asked her on 04/22/2022 at 12:30 AM if she knew were Resident #160 was located. She reported she went to the resident's room, and he/she was not there. Further, she revealed she did not notice the widow. She reported the facility staff started to conduct a room search and a head count when someone stated, look his/her window was open. Per the review, the LPN reported the resident had a table with a chair stacked on top of it. Further review revealed the police were called and the police reported that if the resident did not have a court order then he/she would not have been a missing person. Continued review of the statement revealed the LPN; however, added, he (the police) did not ask about whether the resident was in his/her right mind. Review of the witness statement from the investigation for the former Director of Nursing (DON), undated, revealed she received a call from Licensed Practical Nurse (LPN) #1, on 04/22/2022 at 12:33 AM, and she informed her the resident was missing and she stated, I think he/she went out the window. Further review of the statement revealed the former DON responded by stating, OMG we were just talking about discharge. The former DON revealed LPN #1 reported to her the resident went over the fence. Review of the witness statement from the investigation for the former Executive Director (ED), not dated, revealed that on 04/22/2022 at 12:38 AM, LPN #1 called and informed him the resident left out of the window, over the fence. Further review revealed the former DON informed him the resident was of his/her own mind and the concern was not reportable. Continued review of the statement revealed the ED reported he told staff to notify the police. Review of Resident #160's statement from the investigation, dated 04/23/2022 with no time indicated, revealed the homeless shelter contacted the facility. Continued review of the statement revealed the resident stated he/she was frustrated with his/her court case and was needing to get to his/her county to work on a schedule. Further review revealed the resident stated he/she caught a bus to the hospital to obtain a list of medications. The resident stated someone saved him/her and gave him/her ten (10) dollars to catch the bus downtown. Additionally, the resident revealed he/she slept in the woods by the pond the first night and was in the shelter the second (2nd) night. An additional review of Resident #160's statement from the investigation, dated 04/24/2022, revealed the resident reported he/she exited from his/her window and stated he/she, just opened it, you can do that. Review of the local weather for 04/22/2022, per historical data, showed a low temperature of fifty-nine (59) degrees Fahrenheit with high temperature around seventy-nine (79) degrees Fahrenheit with light rain showers in the area. Observation on 06/02/2023 at 9:19 AM, of resident room [ROOM NUMBER]-2, where Resident #160 resided prior to discharge, and was now occupied by a different resident, revealed the window to be at ground level, covered with a blind and intact with window stops in place. Observations of other windows in residents' rooms were set up the same. In an interview on 06/11/2023 at 11:16 AM, CNA #19 stated Resident #160 had reported to her he/she wanted to get his/her own place when he/she was better. The CNA stated Resident #160 had been anxious about an upcoming court hearing. CNA #19 further stated she did not report this information to anyone. In interview on 06/02/2023 at 1:33 PM, the Maintenance Director stated the window in Resident #160's room was forced open by bending the window stops which made it possible for the window to be raised completely allowing the resident to escape out of it. The Maintenance Director stated he repaired the window after the incident with heavy-duty screws put into place. A telephone interview was attempted with LPN #13 on 06/11/2023 at 11:39 AM; however, was unsuccessful as there was no answer and voicemail had not been set up, so the State Survey Agency (SSA) Surveyor was unable to leave a message requesting a return call. In an interview on 06/10/2023 at 11:11 AM, the former SSD stated she had attempted to have a conversation with Resident #160 about a court date he/she was concerned about which was coming up; however, the resident would not open up to her about it. She further stated the week before Resident #160 exited the facility he/she had asked her about his/her discharge plan from the facility. In an interview on 06/10/2023 at 6:35 PM, the Assistant Director of Nursing (ADON), stated she completed the admission assessment for Resident #160. The ADON stated she recalled Resident #160 was not exhibiting any symptoms that might have indicated the resident was at risk for wandering. However, review of the staffs witnesses statements revealed the resident was anxious and discussed with staff his/her concerns with his/her court hearing and wanted to be discharged to return home on 03/20/2022; sometime within the week of 04/11/2022; and the day before he/she went missing on 04/21/2022. Review of Resident #160's closed medical record revealed there was no documentation to support the interdisciplinary team (IDT) analyzed information obtained from the resident's assessments and observations to identify specific accident hazards or risks for individual residents, to include adequate supervision and monitoring the resident's environment for his/her safety, as mentioned in the facility's policy. In an interview on 06/10/2023 at 9:14 AM, the DON (the former Unit Manager) stated she had received a text from LPN #14 on 04/22/2022 at 12:52 AM alerting her that Resident #160 had left the facility without staff's knowledge. She stated the facility was unaware of Resident #160's location until she received a phone call from staff at a local shelter. The DON stated she and two (2) other staff left to go pick up Resident #160 and he/she agreed to return to the facility with them. Per the interview with the DON, Resident #160 told her people owed him/her money, and stated I just wanted to leave, not getting my med's. The DON stated Resident #160 also told her he/she had already planned to leave. Further, the DON stated Resident #160 told her he/she had taken a nap by the pond near the hospital, and someone came along and gave him/her $10 which the resident used for transportation to the shelter. Review of the facility's smoking policy, effective date 10/08/2017, revealed it was the policy to provide a safe, functional, sanitary, and comfortable environment for all residents, including those that did not smoke, regarding smoking, smoking areas, and smoking safety. 2. Review of Resident #161's closed medical record revealed the facility admitted the resident on 08/10/2022, with diagnoses which included Type I Diabetes Mellitus, Chronic Kidney Disease (CKD), Cognitive Communication Deficit, Left below the Knee Amputation and Bipolar Disorder. Review of the five (5) day MDS assessment dated [DATE], revealed the facility assessed Resident #161 as having a BIMS score of fifteen (15) which indicated the resident's cognition was intact. Review of the Long-Term Care Self-Report Incident Investigation Form, initiated on 08/14/2022, revealed Resident #161 exited the back door of the facility by pushing the bar until it released. Per the review, Resident #161 was in his/her wheelchair which he/she was able to self-propel. Continued review revealed the door alarm sounded on 08/14/2022 at 9:40 PM, which alerted staff and staff responded. Certified Nursing Assistant (CNA) #26 located the resident outside of the facility, on the ground. Continued review revealed the wheels of the resident's wheelchair ran off the edge of the sidewalk, which caused the wheelchair to tilt, and the resident turned over. Continued review revealed Licensed Practical Nurse (LPN) #12 also responded and helped the CNA assist Resident #161 back into his/her wheelchair and back into the building. Review further revealed LPN #12 assessed Resident #161, provided first aid, and observed an abrasion to his/her left stump (a residual limb). Review of Resident #161's smoking assessment, dated 08/15/2022, revealed the resident was assessed to require the use of a smoking apron and assessed to have supervision while smoking. Review of Resident #161's Comprehensive Care Plan dated 08/15/2022 revealed the facility care planned the resident for a risk to exit seek related to his/her desire to smoke without supervision. The facility; however, failed to assess the resident for smoking upon admission to ensure his/her care plan was developed and implemented to indicate a need for assisted and supervised smoking. Review of the Nursing Progress Note documented as a Late Entry on 08/14/2022 at 9:45 PM, by Licensed Practical Nurse (LPN) #12 revealed Resident #161 had been found outside an exit door. Per review of the Note, Resident #161 was assessed for injuries and a small abrasion was observed to the resident's left below the knee amputation (L BKA) area. Continued review revealed his/her vital signs were assessed and neurological checks were initiated and were noted to be within normal limits (WNL). Review revealed Resident #161 was assisted up and back into the wheelchair, and back into the building and then to bed. Further review revealed the resident reported to LPN #12 that he/she had gone out to smoke. Review further revealed Resident #161 was educated by LPN #12 of the facility's smoking policy and was to adhere to it. Review of a Social Service Progress Note, dated 08/15/2022 at 1:02 PM, revealed the Social Worker had met with Resident #161 to review the facility's smoking policy. Continued review revealed Resident #161 verbalized understanding of the policy; however, he/she refused to give staff his/her smoking materials and told the Social Worker, I will smoke when and where I want. I feel like you are trying to control me and take away my independence. Interview on 06/02/2023 at 10:54 AM, revealed Licensed Practical Nurse (LPN) #4 stated she was passing medications when another resident needed to go to the bathroom, so she stopped and took care of that resident. LPN #4 stated next, she headed to pass medications to Resident #161; however, the resident was not in his/her room. The LPN further stated she did not recall much about the incident since it had been so long ago. Telephone call attempts made to contact CNA #28, on 06/02/2023 at 10:50 AM and on 06/04/2023 at 3:38 PM were unsuccessful. 3. Review of Resident #359's closed clinical record revealed the facility admitted the resident on 02/16/2023, with diagnoses of Chronic Kidney Disease, Stage Four (4) (Severe); Type Two (2) Diabetes; and Acquired Absence of Left Leg Above Knee. Review of the Admission MDS Assessment for Resident #359 dated 02/20/2023, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of a possible fifteen (15) (BIMS), which indicated he/she was cognitively intact. Continued review of Section G of the MDS revealed the facility assessed Resident #359's functional status and Activities of Daily Living (ADL) support to require assistance of two (2) plus persons for bed mobility and transfers. Review of Resident #359's Comprehensive Care Plan (CCP), initiated on 02/16/2023, revealed the facility had care planned the resident for skin integrity with a goal for the resident's skin to remain intact. Continued review revealed interventions included: using a pressure reducing mattress; turning and repositioning; assistance with bed mobility by using one (1) or two (2) staff to turn and reposition him/her in bed as needed. Further review revealed the resident was assessed to have two (2) persons assist for bed mobility and transfers; however, the facility failed to care plan, related to the resident's assessed needs and failed to ensure interventions related to the monitoring and documentation of the resident's dressing changes that resulted in the resident's skin tears. Review of the Wound Physician's Progress note dated on 03/06/2023, revealed Resident #359 had been treated for five (5) wounds/skin tears. Continued review of site one (1) revealed it was resolved and was a skin tear to the right, posterior thigh, and site two (2) was a skin tear of the right shin. Continued review revealed site three (3) was a Stage two (2) pressure wound of the right buttock, and site four (4) was a skin tear wound of the right, posterior, lateral thigh, and site five (5) was a skin tear of the right, lower knee. Further review revealed according to a written statement from the Wound Care Nurse, wound sites 1, 2, and 3 were present upon Resident #359's admission to the facility. In addition, review revealed skin tears, listed as sites 4 and 5 resulted from changing the dressing on the wounds at sites 1 and 2. Review of Resident #359's Skin Observation Tool dated on 03/07/2023, revealed a new skin tear had occurred to his/her left upper arm/antecubital area (region of the arm in front of the elbow). Review of Nursing Progress Note dated 03/07/2023 at 9:37 PM, revealed the skin tear to Resident #359's left upper arm was documented and the Nurse Practitioner was notified with orders received for care to the new wound. Continued review of the Note revealed there was no documentation to support the reason for the resident's skin tear. Further review of Resident #359's closed clinical record revealed the resident was discharged on [DATE]. In an interview on 06/01/2023 at 3:41 PM, CNA #9 stated he pulled Resident #359 up in bed by himself which resulted in the resident getting a skin tear on his/her arm. The CNA stated he felt he could pull the resident up on his own, and he did not need another staff member to help. In an interview on 06/01/2023 at 11:20 AM, CNA #6 stated when Resident #359 was admitted to the facility, his/her skin had bruising and wounds. She stated Resident #359 had sustained additional skin tears while at the facility; however, she was unsure of where they came from. Further, she stated Resident #359 had not reported to her of any staff member that was rough providing his/her care, although she admitted the resident's skin was fragile and prone to tearing. In an interview on 06/01/2023 at 8:35 PM, Registered Nurse (RN) #2 stated she remembered an incident with Resident #359 in which CNA # 9 told her he pulled up the resident in bed by himself. RN #2 stated the CNA reported as a result Resident #359 sustained a skin tear to his/her left upper arm. In an interview on 06/03/2023 at 8:50 AM, RN #4/Wound Care Nurse stated Resident #359 had three (3) wounds on admission to the facility. She stated the resident sustained two (2) skin tears that were documented by the wound care physician as a result of wound care dressings being changed and the removal of the dressing by nursing resulted in skin tears. In an interview on 06/10/2023 at 5:42 PM, the DON stated her expectation was that if a skin tear happened during a dressing change, she expected it to be documented and an incident report completed. She further expected proper notification of the provider and the family if an incident occurred. She stated treatment orders were needed, as well as, a skin assessment, and a pain evaluation. The DON stated that if the process was not followed, she would have educated the nursing staff, because not following the process would cause a delay in care, treatment, or even cause the resident to suffer an infection. Interview with Executive Director (ED), on 06/10/2023 at 7:17 PM, she stated her expectation was that skin tears were documented. She stated the resident must first be assured that they were safe. Following that, the provider should have been notified, and the staff were expected to follow the physician's orders. She stated the process was in place to protect the resident and to ensure the healing of the resident's skin tear. 48266

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure a safe, clean, comfortable, and homelike environment. Observations of the linen storage revealed linens were not available to provide resident grooming, hygiene, and a comfortable bed for five (5) of twenty-four (24) sampled residents (Residents #6, #14, #25, #53 and #78). Observation of residents' pillows on their beds were not in good condition. The pillows were covered with a pillowcase, but the condition of the pillows exposed the resident to the potential unsanitary environment as the barrier on the pillowcase was no longer intact. The facility failed to ensure the residents were provided the necessary linens to provide for proper grooming, hygiene, and clean, sanitary, and comfortable beds. The findings include: Review of Resident #65's Admission Record revealed the facility admitted the resident on 01/04/2023 with diagnoses of Unspecified Spina Bifida with Hydrocephalus, Neuromuscular Dysfunction of the Bladder, and Paraplegia. Review of Resident #65's Admission Minimum Data Set (MDS) assessment, dated 04/12/2023, revealed the facility assessed the resident with a score of fifteen (15) out of fifteen (15) on the Brief Interview for Mental Status, (BIMS) assessment for cognition. This score indicated the resident was cognitively intact. Review of Section G revealed the resident required two plus (2+) person assistance for bed mobility and transfers. Observation of room [ROOM NUMBER], bed #2, on 05/31/2023 at 9:23 AM, revealed a pillow without an intact barrier and the covering was frayed and looked dirty. Observation of room [ROOM NUMBER], bed #2, on 06/03/2023 at 5:56 AM, revealed a pillow on the bed that was frayed and coming apart. Observation of room [ROOM NUMBER], bed #1, on 06/03/2023 at 7:57 AM, revealed the pillow's outer plastic casing was split, and the fabric inner pillow casing was exposed. Observation of room [ROOM NUMBER], bed 2, on 06/07/2023 at 11:08 AM, revealed the pillow was torn and ripped. During interview with Resident #65, on 06/06/2023 at 9:55 AM, he/she stated he/she felt like the staff would not take time and the initiative to make sure his/her bed and pillow were clean and comfortable. Resident #65 stated he/she was frustrated about this. In an interview with Licensed Practical Nurse (LPN) #10 on 06/10/2023 at 5:10 PM, she stated the pillows should be wiped down with Sani-wipes regularly. The LPN stated otherwise it was an infection risk for the resident. Certified Nursing Assistant (CNA) #3 stated during interview, on 06/10/2023 at 5:18 PM, that keeping the pillows clean and sanitary involved spraying them with a cleaner and wiping them down. She stated this should be done every couple of days, when the resident left the room, had a shower, or when it was dirty. CNA #3 stated the pillow should be discarded when it was cracked, as it may harbor germs. She stated this was important to residents for dignity, as the facility wanted to provide a clean environment for the residents. During the interview with CNA #25 on 06/10/2023 at 5:15 PM, she stated the pillows should be wiped down daily if they were soiled, or when the linen was changed. She stated if the pillows were ripped, they should be thrown away. CNA #25 stated there was a supply closet with new pillows to provide replacement pillows when needed. During interview with the Infection Preventionist, on 06/10/2023 at 7:00 PM, she stated that ripped or cracked pillows could harbor bacteria in the cracks and they should be thrown away. She stated the cracks and bacteria could lead to infections in the resident. Registered Nurse (RN) #4/Unit Manager stated during interview, on 06/10/2023 at 5:00 PM, that the bed linens should be changed on shower days. She stated they be should be disinfected on bed change days, at least twice per week, and the assistants should be cleaning and checking the pillows. RN #4/Unit Manager stated if the pillow was not disinfected, then there would be infection control issues, eventually respiratory or skin infections. During interview with the Director of Nursing (DON), on 06/10/2023 at 5:42 PM, she stated the staff would check the condition of pillows when they changed the residents' beds, on shower days or other times as needed if the bed/linen became soiled. She stated the pillows would be sanitized using wipes, and if the pillow was cracked, it would be thrown away. The DON stated a cracked pillow was not comfortable for the resident, and the resident wouldn't want to lay on it. She stated a clean, comfortable pillow provided for the common dignity for the resident. During interview with the Executive Director (ED), on 06/10/2023 at 7:17 PM, she stated she expected the staff to maintain clean pillows for the residents. She stated the pillows would be wiped and a new pillowcase put on it. She stated if the pillow's batting was exposed, or if the pillow was ripped or stained, it would be discarded. 2. The Director of Nursing (DON) stated during interview, on 06/10/2023 at 5:00 PM, that the facility did not have a policy on linens or their use. Review of the Document titled, 5) Linen Pars found in the main linen closet, on 06/02/2023, revealed the facility's Periodic Automatic Replacement (PAR) level for each item: flat sheets, fitted sheets, pillowcases, towels, wash cloths, gowns, and blankets was one hundred four (104) each for each shift, 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. Review of the Out Count (Linen Delivered) linen log for 06/01/2023 revealed the following linen items were delivered to the nursing staff by the laundry attendant: one hundred six (106) flat sheets, one hundred eight (108) fitted sheets, thirty-three (33) pillowcases, one hundred seven (107) towels, ninety-six (96) wash cloths, thirty-six (36) gowns, and fifty-nine (59) blankets. Review of the In Count (Linen Washed) linen log for 06/01/2023 revealed the same counts for each item and each shift as the Out Count. Review of the Purchase Order, dated 03/03/2023, and delivered on 03/03/2023, revealed the following orders for linen: twelve (12) dozen (144) fitted sheets, two (2) dozen (24) pillowcases, five (5) dozen (60) bath towels, and two (2) dozen flat sheets (24). Review of Purchase Order dated, 04/01/2023, and delivered on 04/01/2023, revealed the following orders for linen: six (6) dozen (72) fitted sheets, five (5) dozen (60) bath towels, two (2) dozen (24) flat sheets, and one hundred (100) dozen (1,200) wash cloths. Review of the Purchase Order dated, 05/03/2023 and delivered on 05/03/2023, revealed the following orders for linen: five (5) dozen (60) bath towels, six (6) dozen (72) fitted sheets, two (2) dozen (24) flat sheets, and one hundred (100) dozen (1,200) wash cloths. Review of the Purchase Order dated, 06/01/2023, and delivered on 06/01/2023, revealed the following orders for linen: fifteen (15) dozen (180) bath towels and forty (40) dozen (480) washcloths. Review of Purchase Order delivered on 06/17/2023, revealed the following orders for linen: fifteen (15) dozen (180) bath towels, twelve (12) dozen (144) pillowcases, two (2) dozen (24) flat sheets, and one hundred (100) dozen (1,200) wash cloths. However, observation of the facility's linen closet, on 06/03/2023 at 5:20 AM, revealed the linen closet at the main nurse's station had no linen other than forty (40) fitted sheets. There were five (5) linen carts where the facility additionally stored linens. There were two (2) blankets, one flat sheet, and two (2) gowns in the linen cart on the [NAME] Hallway. There were three (3) gowns, three (3) pillowcases, one towel, and four (4) fitted sheets in the cart on the North Hallway. Observation revealed there were six (6) flat sheets, one fitted sheet, and two (2) gowns in the linen cart on the East Hall. On the South Hall, there were seventeen (17) washcloths, one towel, three (3) pillowcases, one gown, two (2) flat sheets, three (3) blankets, and two (2) fitted sheets. On the Lotus Unit, there was another linen cart that contained two (2) blankets, one flat sheet, ten (10) washcloths, four (4) towels, ten (10) gowns, six (6) pillowcases, and several fitted sheets. A. Interview with Resident #25, on 06/01/2023 at 10:00 AM, who stated the facility sometimes did not have enough linen supplies, such as sheets, wash cloths, and towels. He/She stated as a result, he/she would have to wait for his/her shower on his/her scheduled shower day. The resident further stated he/she may not have a wash cloth to wash his/her face. In a follow up interview, on 06/05/2023 at 10:20 AM, the resident stated he/she felt the situation with the linen shortage was getting better, and he/she had received his/her shower/bath the prior day. The resident stated not receiving a bath, made him/her sad. The resident stated he/she did not understand why this was a problem. He/she said, If you ain't got linen, you ain't got linen. B. Review of Resident #53's Admission Record revealed the facility admitted the resident on 12/11/2020 with diagnoses of Generalized Muscle Weakness, Unspecified Atrial Fibrillation, and Morbid (Severe) Obesity Due to Excess Calories. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/18/2023, revealed Resident #53 scored a fourteen (14) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS), assessment for cognition, which indicated the resident was cognitively intact. During interview with Resident #53, on 06/01/2023 at 10:15 AM, he/she stated that he/she relied on staff for Activities of Daily Living (ADLs), including assistance with incontinence. The resident stated, he/she was cold the morning of 06/01/2023, and asked for a blanket, but all the staff provided to him/her was a sheet. On a follow up interview, on 06/03/2023 at 5:45 AM, when interviewed how he/she felt about this issue, the resident stated, What am I doing in this place that can not even manage their linens? C. Review of Resident #14's Admission Record revealed the facility admitted the resident on 04/12/2020 with diagnoses of End Stage Renal Disease, Personal History of Traumatic Brain Injury, and Complete Traumatic Amputation at Knee Level, Left Lower Leg. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/03/2023, revealed Resident #14 scored twelve (12) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment for cognition, which indicated the resident was moderately cognitively impaired. During an interview with Resident #14, on 06/02/2023 at 9:05 AM, the resident stated he/she changed his/her own brief. He/She stated that on the previous day, 06/01/2023, the staff reported to him/her that they could not give him/her a bath because there were not enough towels and/or washcloths to do so. On a follow up interview on 06/04/2023 at 1:40 PM, the resident stated he/she cleaned himself/herself every morning, and sometimes he/she had to use blankets when there were no washcloths. The resident stated this situation did not bother him/her that much, as he/she just improvised and made it work. D. Review of the Annual Minimum Data Set (MDS) assessment, dated 05/04/2023, revealed Resident #78 scored a fifteen (15) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS), assessment for cognition, which indicated the resident was cognitively intact. Continued review of the MDS, Section G, revealed the facility assessed Resident #65 to require two (2) or more persons for his/her bed mobility and transfers. During interview with Resident #78, on 06/06/2023 at 9:53 AM, he/she stated that the staff had told him/her that there were no sheets or no towels in the past. The resident stated he/she was not allowed to keep any linens in the room, and therefore, would not have linen unless staff provided it. He/she stated the issues with shortage of linen affected other residents more than him/her since he/she was not incontinent. E. Review of the Admission Record, in the resident's clinical record, revealed the facility admitted Resident #65 on 01/04/2023 with diagnoses of Unspecified Spina Bifida with Hydrocephalus, Neuromuscular Dysfunction of the Bladder, and Paraplegia. During interview with Resident #65, on 06/06/2023 at 9:55 AM, he/she stated sometimes the staff had told him/her they did not have the linen supplies available when he/she needed to be cleaned or when staff provided incontinence care. The resident stated he/she was told by staff, that he/she would have to wait for the linens to be brought up from the laundry room. The resident stated he/she was frustrated and commented, It's like pulling teeth. Certified Nursing Assistant (CNA) #25 stated during interview, on 06/10/2023 at 5:15 PM, that the facility had ran out of linens before, due to short staffing in the laundry department. She stated there was no second shift laundry attendant, and it delayed her ability to give residents showers on time because she would have to wait on the laundry to get done. CNA #25 also stated she was delayed in providing the residents a clean linen change for their beds due to not having clean sheets to do so. She stated she reported these instances to administration. Interview with CNA #3, on 06/10/2023 at 5:18 PM, who stated the facility was running out of linens about a month ago. She stated she ran out of draw sheets, towels, and washcloths, which she needed in order for her to provide resident care. CNA #3 stated the staff used wipes for incontinent care, so the staff just waited for the laundry attendant to come in to do the laundry to get the linen she needed. During interview with the Laundry Attendant, on 06/02/2023 at 10:52 AM, she stated her hours were 8:00 AM until 4:00 PM. She stated she tried to come in a little early to provide clean linens earlier to staff. She stated there was a shoot on the side of the linen closet for the dirty linen for the North, South, East, and [NAME] Halls that delivered the dirty linen into the laundry room downstairs. However, she stated she picked up the dirty linen from the Lotus Unit in the morning. The Laundry Attendant stated she brought out a load of clean linen every hour and put in the linen closet for the nursing staff. She stated she completed the dirty laundry for the facility around noon, and then she started loads again around 2:00 or 2:30 PM. She stated there were two (2) washers and three (3) dryers, and she completed twelve (12) to fourteen (14) loads per day. The Laundry Attendant stated the PAR level was usually twice the census of the facility. She stated after 5:00 to 6:00 PM, the staff complained they did not have enough linen. She stated she felt linen was thrown away, because by the middle of the month, it seemed she began getting complaints of running short on linen from the staff. She stated that the facility placed an order for linen once a month. During interview with the District Housekeeping Manager on 06/03/2023 at 9:11 AM, she stated she ensured the linen count for the facility. She stated the Executive Director (ED) and the Director of Nursing (DON) looked at the census and applied a multiplier to determine the PAR levels for each individual item of laundry. When interviewed about the posted PAR level of one hundred and four (104) for every linen item, on every shift, with a census of one hundred two (102), she commented that the PAR was wrong. She stated the process was that as the census changed, the PAR level changed. She stated this was determined in the morning meeting and given to the laundry attendant, and then the PAR level would be adjusted. She further stated after reviewing the In and Out Count for the linens delivered and washed that it looked a little low. The District Housekeeping Manager further stated, on 06/03/2023 at 9:11 AM, orders were placed once a month, and that a linen order was placed on 06/01/2023 that would be delivered 06/05/2023. She stated she brought in one hundred eighty (180) washcloths from another facility on 06/01/2023 due to the shortage. During the interview, she stated there was an issue with staffing for the second shift in the laundry, and the Housekeeping Manager was working some in the evenings until the position was filled. During the follow up interview on 06/04/2023 at 2:15 PM, she stated she was provided information regarding the stock of linen. She explained some of the linen had been placed in the rag-out process, which meant their condition was no longer satisfactory for the residents to use. She stated she also searched the facility on 06/03/2023 and located linen that was stored. She stated she found one hundred eight (108) pillowcases that were stored in the laundry room, sixty (60) gowns that were in a storage building outside, and fifty (50) blankets that were added to the stock. She added an additional one hundred forty-four (144) towels from another location to meet the par levels for the facility. She stated the facility had the linens, but the linens were stored and were now found and would be put into use. During interview with the Housekeeping Director, on 06/10/2023 at 3:30 PM, she stated her first day in this position was 05/21/2023. She stated she was still in training with the District Housekeeping Manager on how to use the PAR levels. She stated she thought linen levels were fine, but the District Housekeeping Manager brought it to her attention this was not the case. She stated it should have been common sense to see that the facility was short on linen, because in the laundry room, she would only see a certain amount of linen she was getting back. She stated her supervisor, the District Housekeeping Manager, ordered linen once a month, but a linen order could be placed and delivered the same day if needed. She stated she had come into the facility to check linen levels in the middle of the night to ensure the facility had enough, but she was available by phone if she was ever needed. The Housekeeping Director stated she had also recently hired a second shift attendant that was still in training. She stated she wanted the residents to be able to get baths, and have their basic needs met, such as washing their face. She stated she wanted to be an advocate for them, and residents should not be in filth, discomfort or pain. During interview with the DON, on 06/10/2023 at 5:42 PM, she stated she ensured there was enough linen on the cart before she left for the day to get the staff through the nightshift. She stated if there was not enough linen the staff could not provide showers or incontinent care for the residents. She denied being made aware of a linen shortage since she has been the Director of Nursing. The DON stated if an issue was identified, the staff would notify her. She stated she would take care of it right away by calling in the laundry attendant to wash the linen. During interview with Executive Director, on 06/10/2023 at 7:17 PM, she stated the facility did audits to ensure the staff had enough supplies to provide for the care of the residents. She stated she expected to provide enough clean linen for every shift. 46710

Based on observation, and interview, it was determined the facility failed to store and serve food under sanitary conditions. Observations, during the lunch tray line on 06/06/2023, revealed the dish covers and bowls being used were wet. The Dietary Director was observed drying dishware with a paper towel. Further observation revealed the kitchen ingredient bins were not labeled or dated. The findings include: 1. Observations, on 06/06/2023 at 11:55 AM, during the kitchen tour revealed three (3) ingredient bins were not labeled and dated. In an interview, on 06/09/2023 at 3:38 PM, Cook/Night Supervisor #2 stated ingredients bins which contained sugar, flour, and rice were to be labeled and dated. The Cook/Night Supervisor #2 stated the bins were washed before adding more products. The Cook/Night Supervisor #2 further stated if the bins were not labeled the product inside could be out of date and staff would not know the last date the bin was cleaned. In an interview, on 06/09/2023 at 3:40 PM, Cook/Diet Aide Floater #3 stated the ingredients bins were to be labeled for safe use. In an interview, on 06/09/2023 at 3:56 PM, Regional Clinical Registered Dietitian (RD) stated the ingredient bins were to be labeled and dated to ensure freshness and safety of food. In an interview, on 06/10/2023 at 9:58 AM, the Dietary Manager (DM) stated the ingredient bins were to be labeled and dated when a new food product was added to the bin. In an interview on 06/10/2023 at 5:20 PM, the Director of Nursing (DON) stated all food products should always be labeled and dated. In an interview on 06/10/2023 at 7:17 PM, the Executive Director (ED) stated her expectations for any food product pulled out of the cases was to be labeled and dated with the expiration date. 2. Observation of the lunch tray line, on 06/06/2023 at 12:25 PM, revealed the dish covers being used to cover plates of food were wet and the bowls being used were also wet. Continued observation revealed the Dietary Manager stopped staff from placing the wet dish covers over the plates of food. Further observation revealed the Dietary Manager was then observed in the dish room drying the dish covers and bowls with a paper towel. In an interview on 06/09/2023 at 3:56 PM, the Regional Clinical RD stated dishware taken from the dish machine was to be placed on a cart on the racks to dry. The Regional Clinical RD stated wet dishware was a possible infection control concern. Additionally, the Regional Clinical RD stated drying dishes with a paper towel was a concern as it could result in cross contamination. In an interview on 06/10/2023 at 9:58 AM, the DM stated it was not good practice to use a paper towel to dry dishes because it could cause possible cross contamination. In an interview on 06/10/2023 at 5:20 PM, the DON stated the lids (dish covers) and bowls left wet were an infection control concern and should have been properly dried before use. In an interview on 06/10/2023 at 7:17 PM, the ED stated there was a concern for cross contamination when drying dishware with a towel.

Based on observation, interview, record review, and review of facility policy review, it was determined the facility failed to ensure that residents' right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of twenty-four (24) sampled residents (Resident #65). Observation of Resident #65's mobility was limited to his/her wheelchair. The resident was unable to get to the bathroom sink for personal hygiene due to his/her wheelchair not fitting through the bathroom door. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). Record review revealed the facility admitted Resident #65 on 01/04/2023 with diagnoses of Unspecified Spina Bifida with Hydrocephalus, Neuromuscular Dysfunction of the Bladder, and Paraplegia. Review of Resident #65's Admission Minimum Data Set (MDS) assessment, dated 04/12/2023, revealed the resident scored a fifteen (15) out of a possible fifteen (15) on the Brief Interview for Mental Status, (BIMS)assessment for cognition. This score indicated the resident was cognitively intact. Review of the MDS, Section G revealed Resident #65's mobility required two plus (2+) persons assistance for bed mobility and transfers. Review of Resident #65's Comprehensive Care Plan (CCP), initiated on 01/05/2023 and revised on 01/17/2023, revealed the resident required assistance with Activity of Daily Living, (ADL), related to his/her decreased mobility, debility, spina bifida, paraplegia, and history of hydrocephalus with a ventriculoperitoneal (VP) shunt. The interventions included implementing a bariatric wheelchair, cushion, and a reacher. Further interventions listed in the resident's care plan was assistance times one (1) for bed mobility, dressing, toileting, and bathing. Observation of the resident's room, on 06/10/2023 at 9:30 AM, with the Maintenance Director revealed the Maintenance Director took the measurements of the resident's room. The doorway between the room and the hallway measured forty-two and three-quarter (42 3/4) inches wide. The bathroom doorway measured thirty and three-quarter (30 3/4) inches wide. He measured the wheelchair to be thirty-one and three-quarter (31 3/4) inches wide. The Maintenance Director stated that all doorways to resident bathrooms were the same size in the facility. Resident #65 stated in interview, on 06/07/2023 at 11:18 AM, that he/she could not get into the bathroom with his/her wheelchair to brush his/her teeth, wash his/her hands, or use the sink. The resident stated there was no other place in the facility where he/she could use a sink due to the size of the wheelchair. The resident stated he/she felt frustrated, and it made him/her angry. During an interview with Certified Nursing Assistant (CNA) #25, on 06/09/2023 at 4:03 PM, the CNA stated Resident #65 was independent with grooming. She stated that once the resident was transferred to the wheelchair, he/she would go into his/her own bathroom in his/her wheelchair to perform personal hygiene, brushing his/her teeth and washing his/her hands and face. However, the CNA was unaware the resident's wheelchair would not fit through the door. The Social Services Director (SSD), stated during interview on 06/10/2023 at 7:08 PM, that she had not realized Resident #65's wheelchair was too wide to fit into the bathroom making the bathroom inaccessible to the resident. During interview with Licensed Practical Nurse (LPN) #8, on 06/10/2023 at 8:55 AM, she stated the CNAs were expected to offer assistance to Resident #65 with his/her ADLs. She stated the staff set up what the resident needed for grooming and hygiene on his/her table. The LPN was aware the resident's wheelchair would not fit through the door, and the resident could not use the bathroom sink for personal hygiene. During interview with the Director of Nursing (DON), on 06/09/2023 at 9:10 AM, she stated the facility was responsible for providing Resident #65 a basin on his/her table in the morning for dental care and to wash his/her hands and face. She stated the resident was able to do this independently once provided the assistance needed. The DON stated she was unaware the resident could not get into the bathroom in his/her wheelchair. She stated she would discuss with the resident a room change with a sink outside the bathroom to allow the resident to perform personal hygiene. In the interview on 06/10/2023 at 7:17 PM, the Executive Director (ED), stated the fact that the resident's wheelchair would not fit through the door into the bathroom, prohibiting the resident to have access to the sink was an issue of dignity for the resident. She stated she expected residents to do as much for themselves as they possibly could.

Based on interview, record review, and facility policy review, it was determined the facility failed to report allegations of abuse within two (2) hours for one of twenty-four (24) sampled residents (Resident #34). On 05/05/2023, Certified Nurse Assistant (CNA) #18 heard an allegation from Resident #82 that Resident #312 groped Resident #34's genitals. However, CNA #18 stated she reported this to Registered Nurse (RN) #5 on 05/05/2023. However, staff failed to report this allegation to the Executive Director until four (4) days later on 05/09/2023. The findings include: Review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 09/2022, revealed the facility's staff reported allegations of abuse to the abuse coordinator immediately. Further review revealed that immediately was defined as within two (2) hours for an allegation involving abuse. Review of the facility's investigation revealed CNA #18 was in the dining room at lunch on 05/05/2023 and overheard Resident #82 state he/she saw Resident #312 with his/her hands on Resident #34's leg and then in Resident #34's brief. Further review revealed CNA #18 wrote a statement that she reported the allegation to Registered Nurse (RN) #5 on 05/05/2023. Continued review revealed CNA #18 failed to report the suspected abuse to the Executive Director until 05/09/2023, four (4) days after the she overheard the allegations, at which time the facility reported the allegations to state agencies. 1. Review of Resident #312's Admission Record revealed the facility admitted the resident on 02/21/2023 with diagnoses that included Traumatic Subdural Hemorrhage (brain bleed), Cognitive Communication Deficit, and Alcohol Dependence. Review of Resident #312's Care Plan, dated 03/08/2023, revealed the facility assessed the resident as being at risk for psychosocial disturbances and included an intervention of providing 1:1 care as appropriate. Review of Resident #312's Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) examination, with a score of fifteen (15) of fifteen (15) which indicated the resident was cognitively intact. 2. Review of Resident #34's Admission Record revealed the facility admitted the resident on 09/30/2021 with diagnoses that included Heart Failure, Type II Diabetes, and Bipolar Disorder. Review of Resident #34's Care Plan, dated 05/09/2023, revealed the facility identified the resident was at risk for psychosocial disturbance due to a history of anxiety and depression, as well as allegations of unwanted sexual contact. Further review revealed the facility included interventions such as administering medications as ordered and monitoring the resident for signs and symptoms of psychological distress. Review of Resident #34's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS), with a score of eleven (11) out of fifteen (15), indicating the resident was moderately cognitively impaired. 3. Review of Resident #82's Admission Record revealed the facility admitted the resident on 03/14/2023 with diagnoses that included Cirrhosis of the Liver, Spinal Stenosis, and Cocaine Use. Review of Resident #82's Quarterly Minimum Data Set, dated dated dated [DATE], revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) examination with a score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Interview was attempted with Resident #312 on 06/01/2023 at 3:07 PM. However, the phone number available for him/her was out of service. Resident #34, in an interview on 06/03/2023 at 2:12 PM, stated Resident #312 had not touched him/her inappropriately at any time. Resident #82, in an interview on 06/02/2023 at 5:11 AM, stated he/she saw Resident #312 and Resident #34 sitting at a table together. The resident stated he/she did not know what Resident #312 was doing with his/her hands under the table. Resident #82 was not able to answer further questions. In an interview on 06/03/2023 at 5:21 PM, CNA #18 stated she overheard Resident #82 tell another resident that he/she had seen Resident #312 with his/her hands in Resident #34's brief. CNA #18 stated she reported the allegation to Registered Nurse (RN) #5, and she did not immediately report it to the Executive Director (ED) because she thought RN #5 would do it. CNA #18 stated she had received training about reporting abuse to a supervisor and she believed the nurse was her most direct supervisor. In an interview on 06/03/2023 at 5:36 PM, RN #5 stated CNA #18 did not report the allegations to her. She stated her process when a CNA told her about abuse allegations was to call the Executive Director with the CNA beside her to discuss the allegations and appropriate follow-up actions as a team. RN #5 stated she would have done this if CNA #18 had reported to her. In an interview on 06/10/2023 at 11:54 AM, the Assistant Director of Nursing (ADON) stated CNA #18 failed to report the allegations made by Resident #82 for four (4) days. In an interview on 06/09/2023 at 3:34 PM, the former Director of Nursing (DON) stated CNA #18 failed to report the allegations of abuse she overheard from Resident #82 in a timely manner. The former DON stated CNA #18 said she reported the allegations to RN #5, but she should have also reported the allegations to the Executive Director. In an interview on 06/10/2023 at 6:42 PM, the Executive Director (ED) stated her expectation was for any staff member, including CNAs, to call the Abuse Coordinator, who was usually the ED, immediately.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure all assessments accurately reflected the resident's status for one (1) of twenty-four (24) sampled residents (Resident #359). Review of the Admission Minimum Data Set (MDS) Assessment, dated 02/20/2023, revealed the resident was not assessed accurately for pressure. The MDS coded Resident #359 as having no pressure ulcer upon admission, however, it was documented by the Advanced Practice Nurse Practitioner (APRN) that the resident had a pressure wound present on his/her right buttock. The findings include: Review of the Resident Assessment Instrument (RAI) MDS 3.0 Manual revealed the steps for skin assessments included: (1) Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments; (2) Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident; (3) Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices were present, including to assess key areas for pressure ulcer/injury development (sacrum, coccyx, trochanter's, ischial tuberosities, and heels). Closed record review revealed the facility admitted Resident #359 on 02/16/2023 with diagnoses which included Chronic Kidney Disease, Stage Four (4) (Severe), Type Two (2) Diabetes, and Acquired Absence of Left Leg Above Knee. Review of Resident #359's Admission Minimum Data Set (MDS) Assessment, dated 02/20/2023, revealed the resident scored a fifteen (15) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), assessment for cognition, which indicated the resident was cognitively intact. Review of Section M-Skin Conditions, revealed in M 0100: The determination of Pressure Ulcer/Injury Risk was by the formal assessment instrument/tool (Braden, [NAME], or other) and clinical assessment. Review of M 0150: Risk of Pressure Ulcers/Injuries revealed the facility answered 'yes', to the question, 'Is this resident at risk of developing pressure ulcers/injuries?' M 0210: Unhealed Pressure Ulcers/Injuries was answered 'no', to the question, 'does this resident have one or more unhealed pressure ulcers/injuries?' However, review of the Provider Progress Notes, dated 02/17/2023, revealed Advanced Practice Registered Nurse (APRN) had conducted a comprehensive assessment of the resident upon admission. She documented a wound on the resident's right buttock that was present on admission. Review of the Wound Care Physician Progress Notes, dated 02/27/2023 revealed a Stage two (2) pressure ulcer on Resident #359's right buttock was added to the treatment plan. Site #1 was the skin tear wound on the right posterior thigh, and site #2 was the skin tear wound on the right shin. Site #3 was a Stage two (2) pressure wound of the right buttocks. Review of Resident #359's Electronic Medical Record, (EMC) Admission/Re-admission Nursing Evaluation, dated 02/16/2023, revealed the nurse documented an unhealed wound to the resident's right thigh. She also noted various dark purple spots to the bilateral lower extremities (BLE) and shoulder; reddened, shiny right lower extremity (RLE); and an old amputation scar to the left lower extremity (LLE) above the knee amputation (AKA) and left dorsal. During interview with Registered Nurse (RN) #2, on 06/04/2023 at 6:40 PM, she stated Resident #359 was able to turn in bed for her to assess his/her skin. She stated if Resident #359 had a pressure ulcer upon admission, she would have documented it upon admission. However, she was unsure whether the resident had a pressure wound upon admission since it was not documented. During interview with the Former MDS Coordinator, on 06/04/2023 at 3:56 PM, she stated her process for completing the Admission MDS assessment included assessment of several areas. However, she did not do skin assessments She stated she relied on the nursing admission assessment for the information she added to the MDS assessment. During further interview, she stated she would update the MDS the next day after the Admission Nursing Assessment was completed to reflect the skin conditions or issues that the nurse had identified. The Former MDS Coordinator stated she also looked at hospital records or wound care notes to update the information on the MDS. She stated if she found no evidence of skin conditions documented, she would document on the MDS that the resident had no skin issues. She further stated it was not her practice to interview cognitively competent residents regarding any skin conditions they had during her assessment. She stated when she discovered an error in the MDS assessment, she would go back, modify the answer, and submit a correction. During interview with the APRN, on 06/05/2023 at 9:00 AM, she stated she assessed and documented a wound on the resident's right buttock on admission. She stated she would not stage wounds, but she ordered a consult with the in-house wound care physician that would treat the wound and stage it as well. During interview with the Director of Nursing (DON), on 06/10/2023 at 5:42 PM she stated her expectation of her nursing staff was that the nursing admission assessment would have included whatever skin issue the resident had. The DON stated she expected the MDS Coordinator to reflect all skin issues when doing the Admission MDS Assessment as well. She stated this was important in providing person-centered care. The DON stated she believed that if a resident had a wound that the nursing staff failed to assess and document upon admission, that resident's wound would not be treated and possibly could worsen. In an interview with Executive Director (ED), on 06/10/2023 at 7:17 PM, she stated she expected residents' skin to be assessed upon admission. She stated a resident with a pressure wound upon admission should have the wound documented completely and accurately by the MDS Coordinator and other nursing staff at the time of admission. She stated she expected nursing to follow the facility's processes of meeting standards of care. She stated she felt if a wound was not identified on admission, it could have possibly worsened.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to protect residents from neglect by failing to provide the necessary goods and services for one (1) of nine (9) sampled residents (Resident #2). The facility admitted Resident #2 at approximately 12:15 PM on 04/17/2021. Staff entered Resident #2's information into the facility's Electronic Health Record (EHR) at 2:05 PM. However, Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to document completion of Resident #2's admission assessments. Resident #2 requested to return to the hospital due to unrelieved abdominal pain on 04/18/2021 at 12:40 AM, approximately twelve (12) hours after his/her admission. The hospital admitted Resident #2 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was also diagnosed with bilateral Pleural Effusions (excessive fluid build up around the lung) and Dyspnea (shortness of breath). The facility's failure to take immediate action to prevent neglect and to follow their policy to ensure all residents were free from neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/2021 and was determined to exist on 04/17/2021. Immediate Jeopardy was determined to exist at CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), CFR 483.25 Quality of Care (F697). The facility was notified of the Immediate Jeopardy on 09/13/2021. The facility submitted an acceptable Allegation of Compliance (AOC) on 09/17/2021 and alleged removal of immediacy on 09/17/2021. The State Survey Agency validated removal of the Immediate Jeopardy, before exit, on 09/17/2021, as alleged. The findings include: Review of the facility's policy entitled, Freedom from Abuse and Neglect, dated 10/30/2019, revealed the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional stress. Further review revealed the facility was to conduct an investigation of any alleged abuse or neglect and would notify the proper authorities. Review of the facility's policy, Resident Rights, revised 12/2016, revealed federal and state laws guaranteed certain basic rights for all residents residing in the facility. The rights included: being treated with respect, kindness and dignity; remaining free from abuse, neglect, misappropriation of property and exploitation; and having equal access to quality care, regardless of the source of payment. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 04/17/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed no documented evidence of completed admission paperwork; transportation documentation; completed laboratory (labs) documentation; a dietary slip which noted the resident's diet orders; or of assessments completed upon admission. Further review also revealed no documented evidence of staff's monitoring of Resident #2's oral food and fluid intake. Review of the facility's Current Weight and Vitals, documentation for Resident #2 dated 04/17/2021, revealed no documented evidence staff obtained the resident's height, weight, respirations, temperature, blood glucose level, oxygen saturation level or pain level after his/her admission to the facility. Continued review revealed Certified Medication Technician (CMT) #1 documented that she had obtained Resident #2's blood pressure and heart rate at 9:54 PM, approximately ten (10) hours after the resident's arrival at the facility. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the Physician had prescribed medications for Resident #2 which included medications for hypertension, pain, intravenous (IV) antibiotics; and, insulin which was to be administered at bedtime. Per review, there was no documented evidence of orders for monitoring Resident #2's blood glucose monitoring, nor an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #2 missed three (3) potential administrations of pain medication, one scheduled administration of insulin and one scheduled administration of his/her intravenous antibiotic. Review of Resident #2's Progress Notes revealed a late entry note completed by Licensed Practical Nurse (LPN) #1, on 04/21/2021, dated 04/17/2021 which noted the resident arrived at the facility at approximately 12:15 PM. Continued review of the Progress Notes revealed another late entry note, on 04/21/2021 completed by Registered Nurse (RN) #1, for the date of 04/17/2021 at 12:32 PM, which documented Resident #2's vital signs had been obtained, and noted the resident was oriented to his/her new room. Per review of RN #1's late entry note, Resident #2 was provided a lunch tray per the diet ordered, and the orders had been verified with the Physician. Interview with Resident #2 on 09/02/2021 at 11:54 AM, revealed he/she arrived at the facility around 12:00 PM on 04/17/2021, via ambulance. Resident #2 stated he/she was in the facility for approximately five (5) or six (6) hours, and did not see or hear from any of the staff. Resident #2 stated that he/she walked up the hallway to the Nurse's Station after the five (5) to six (6) hour interval to speak to the staff person sitting at the desk. The resident stated the staff person told him/her they were unaware that he/she (Resident #2) had been admitted as that information had not been given to her during shift report. Continued interview revealed Resident #2 requested pain medication from the staff person, who was the night shift nurse. However, the resident stated that he/she did not receive the pain medication after requesting it, and did not receive the ordered antibiotic while in the facility. Resident #2 stated the night shift nurse told him/her the pain medication ordered would not be delivered to the facility until 04/18/2021 around 2:00 AM. According to Resident #2, he/she had experienced several surgeries to his/her buttock related to the abscess and infection. Resident #2 stated the surgical areas on his/her buttock caused him/her a lot of pain when doing pretty much anything, like walking, sitting, lying down, or using the bathroom. Further interview revealed Resident #2 was an insulin dependent diabetic and no one had checked his/her blood glucose level, or administered his/her ordered insulin. Resident #2 stated he/she requested to be sent back to hospital when he/she experienced abdominal pain. Resident #2 further revealed he/she returned to the hospital after being in the facility for approximately twelve (12) hours. Additionally, Resident #2 stated while in the hospital's Emergency Department (ED), staff administered the IV antibiotic which he/she had missed while residing at the facility. Review of the hospital's documentation for Resident #2 dated 04/18/2021, revealed the resident had reported to ED staff that he/she requested to leave the facility to return to the hospital. Per review, Resident #2 was admitted to the hospital and diagnosed with [CONDITION(S)], Dyspnea, and bilateral Pleural Effusions. Further review revealed Resident #2 had an oxygen saturation level of 89% (below 90 percent was considered to be low blood oxygen also known as hypoxemia) and required oxygen therapy. Interview with Licensed Practical Nurse (LPN) #2, on 09/07/2021 at 10:03 AM, revealed she was the 7:00 PM to 7:00 AM (night shift) nurse who took over Resident #2's care from LPN #1 on 04/17/2021. Per interview, LPN #2 had not received information on Resident #2 being a new admission, in the shift exchange report she received from LPN #1. She stated she only became aware of Resident #2's presence when she started passing medications to other residents, and noticed the resident's call light kept coming on. LPN #2 stated she entered Resident #2's room to see if she could help the resident with anything, and the resident's main focus was pain and not having received the requested pain medication. Interview with LPN #2 revealed she was unaware Resident #2 requested pain medication previously and LPN #2 was unable to identify the staff member to whom Resident #2 spoke. According to LPN #2, Resident #2 told her that he/she would leave the facility Against Medical Advice (AMA) if his/her pain medication wasn't administered soon. Continued interview revealed Resident #2 told her he/she had been in the facility for several hours with no assistance from staff. LPN #2 stated that no one had reported to her that Resident #2 was a diabetic, who was insulin dependent and required glucose monitoring and insulin administration. Per the LPN, during her shift on 04/17/2021, there had been no documentation for her to review such as Progress Notes which noted the previous staff had assisted Resident #2, or attempted to complete the admission requirements for him/her. The LPN stated if Resident #2 had required monitoring for some reason, like blood sugars, it should have populated on the resident's MAR (Medication Administration Record) if the orders had been entered into the facility's EHR. LPN #2 also stated once she was aware of Resident #2 being a new resident, her main concern was trying to manage the resident's apparent pain. Interview revealed LPN #2 notified the Director of Nursing (DON) of Resident #2's concerns regarding having no assistance from staff after hours in the facility, and of the resident not receiving any pain medication. The LPN stated the DON directed her to call the Pharmacy to confirm when Resident #2's medications were to be delivered to the facility. Further interview revealed she was unable to explain what had happened with Resident #2's admission. She stated; however, when she received a new resident for admission she went to the resident's room as soon as possible to meet him/her and do the admission inventory list. Per interview, she also ensured the new resident's bedside was set up with the things he/she might need. LPN #2 further stated she also completed a skin assessment of newly admitted residents assigned to her as anything could happen during the transfer to the facility. The State Survey Agency Surveyor attempted telephone (phone) contact with Licensed Practical Nurse (LPN) #1, and Certified Nurse Assistant (CNA) #1, who were assigned to Resident #2's care on the 7:00 AM to 7:00 PM, on the day of admission. However, all phone contact attempts were unsuccessful. Interview with the Executive Director on 09/10/2021 at 1:15 PM, revealed LPN #1 and CNA #1 were no longer employed by the facility. Interview with RN #1, on 09/07/2021 at 9:44 AM, revealed when she received a new admission she went to the resident's room to introduce herself, and obtain his/her vital signs for a baseline. Per interview, RN #1 completed a skin assessment, and ensured a meal was provided or needed for a resident who had missed a meal. Continued interview revealed it was important to see a new resident as soon as possible after they arrived to ensure the person was in a stable condition. She stated if staff didn't do that in a timely fashion and establish a baseline, the facility would not be aware if the resident experienced a change in his/her status. Further interview with RN #1 revealed she could not recall Resident #2 specifically or if she assisted with his/her admission. Per the RN, if she had not been assigned to Resident #2's care, and had been the one who entered the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, RN #1 could not recall why she completed a late entry progress note four (4) days after the resident was admitted to the facility. Interview with LPN #3, on 09/10/2021 at 9:59 AM, revealed when she was assigned a new admission she went to meet the resident as soon as possible to obtain his/her vital signs and perform skin and/or wound assessments of the resident. She stated it was important for staff to ensure all assessments and any concerns noted were documented on admission in order for them to be addressed. Continued interview revealed it was very important to ensure all orders were entered into the resident's EHR as quickly as possible so the pharmacy could be working on filling the new resident's prescriptions and deliver them to the facility. Additionally, she revealed if a facility resident did not receive the care and services they needed it could be considered neglect, which was unacceptable. Interview with RN #3, on 09/10/2021 at 9:48 AM, revealed when she was assigned a new resident's admission, she went to their room as soon as she could to meet them, complete their vital signs and perform a skin assessment to establish their baseline information. Per interview, she stated she did this so that she and other staff could monitor the new resident for any change of status. RN #3 stated she also sent the new resident's medication orders to pharmacy as quickly as they were available to prevent the resident from missing any doses. Further interview revealed if she or other nursing staff failed to complete all of the admission tasks in a timely manner, and the new resident missed his/her medications, the facility did not provide the resident's required care and services. RN #3 further revealed that could be considered neglect of the new resident. Interview with the Nurse Practitioner (NP), 09/09/2021 at 9:00 AM, revealed she was on call for the Medical Director twenty-four (24) hours a day seven (7) days a week. She stated she recalled being notified when Resident #2 arrived at the facility, and recalled verifying the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, she would have came to the facility on [DATE], to see Resident #2 if he/she had not been sent out to the hospital. Continued interview revealed staff should have entered a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if the facility had not been monitoring Resident #2's blood glucose while he/she was there, and the resident's blood sugar had dropped there could have been issues for the resident. Further interview with the NP revealed she had received a phone call on 04/18/2021 around 1:00 AM, from facility staff requesting Resident #2 be sent back to the hospital per the resident's request. She further stated staff should always contact her as soon as possible after a new resident was admitted to ensure the new resident was prescribed the correct medications and if changes were necessary they could be done. Interview with the facility's previous Director of Nursing (DON), on 09/13/2021 at 9:50 AM, revealed she was unable to recall Resident #2's admission to the facility, or any identified concerns regarding the resident's admission. The DON stated when a new resident was admitted the Physician was to be notified to verify the new resident's orders. Continued interview revealed nursing staff was to send the verified orders for the medications and/or treatment medications to the Pharmacy as quickly as possible in order for Pharmacy staff to fill the prescriptions and get them to the facility. She stated the nurse assigned to the newly admitted resident was responsible for ensuring all those things were completed in a timely manner. Further interview revealed on the next business day following new residents' admissions, facility staff reviewed all the admissions to ensure the completeness of the admission information. The previous DON stated it was up to the assigned nurse's judgement to determine what things on the new admission checklist for a new resident needed to be completed timely. Interview with the acting DON, on 09/10/2021 at 1:47 PM, revealed she was hired in August 2021. She stated when new residents were admitted the nurse assigned was provided with a new admission checklist. The new admission checklist was completed to ensure all aspects of a new resident's admission were completed. Per review, staff in the facility's clinical meeting also reviewed the new resident's admission information as a backup to ensure everything was completed as per policy. She stated things such as vital signs, skin assessments and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed those things were done to gather a baseline for the new resident and to assess his/her current needs. The DON stated if those things were not completed timely, staff would not be aware of the new resident's needs. Further interview revealed the facility had identified concerns with admissions and was currently reevaluating the new admission checklist, and how their EHR system triggered when assessments were due. In addition, she revealed the concerns regarding the facility's admission process would be taken to their Quality Assurance Performance Improvement (QAPI) meetings for review. Interview with the previous ED, on 09/10/2021 at 1:31 PM, revealed when a nurse received a new resident for admission she expected the nurse to meet the resident, and ensure all the assessments were completed within twenty-four (24) hours. Per interview, she expected the nurses to ensure the Physician was notified to verify the new resident's medication orders, and make sure the orders were sent to the Pharmacy in a timely manner. The previous ED stated she had not identified any concerns with the facility's admission process. Further interview revealed the facility had processes in place to ensure new residents received their medications without missing doses. She further revealed staff were expected to follow the processes to ensure new residents received the goods and services they needed. Interview with the current ED, on 09/10/2021 at 1:15 PM, revealed she had been hired at the facility for three (3) weeks. Per interview, she expected facility staff to follow the admission policy and complete the admission checklist within the given time frame. Per interview, she also expected staff to make the proper notifications to the Provider to ensure new residents' goods and services were being administered as required. The facility alleged it implemented the following actions to remove immediacy: 1. Resident #2 no longer resides in the facility. 2. The ED and DON, notified the Physician of the event, and held an ADHOC QAPI meeting on 09/13/2021, to discuss the event and discussion of developing an action plan to address the event. 3. The DON conducted an audit of resident admissions for the past thirty (30) days, starting on 09/08/2021, to determine if assessments were completed and to ensure orders were reviewed and verified along with ensuring medications were available. 4. The DON, ADON, UM, and/or the VPCS were to reeducate all licensed staff, including agency staff, on or before 09/16/2021, regarding the following: admission policy; order verifications; admission assessments; and the process for obtaining medications from the pharmacy, including a posttest. Staff not available were to be reeducated on return to work and new hires were to be provided the education during orientation. 5. The IDT (Interdisciplinary Team) was to review new admissions during morning meeting to ensure the admission was complete, orders were verified and medications were available to be administered. IDT was to review this starting 09/17/2021 daily for two (2) weeks. 6. The ED and/or DON were to review audit results weekly for four (4) weeks. 7. The DON and/or the ED were to report the audit results weekly to the QAPI Committee. The State Survey Agency (SSA) validated the facility's removal of immediacy plan by: 1. Record review revealed Resident #2 was discharged on [DATE] and was no longer in the facility. 2. Review of the facility's documentation revealed an ADHOC meeting was held on 09/13/2021 with the ED, DON, and Physician in attendance. Interview with the ED, DON, and Physician on 09/17/2021 revealed during the ADHOC meeting, the SSA findings were discussed and steps were identified to remove the immediacy and to ensure the identified concerns would not reoccur. 3. Review of the facility's documentation revealed an audit was completed by the DON of the past thirty (30) days of admissions, starting on 09/08/2021. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed she completed the audit and any identified concerns were corrected immediately upon discovery. 4. Review of the facility's documentation revealed education was provided to all licensed staff on or before 09/16/2021, with a posttest administered. Continued review revealed certified letters were mailed to employees who had not yet received the education. Interview with DON, ADON, and Unit Manager (UM), on 09/17/2021, revealed they had completed education with licensed staff. Per interview, the staff the facility was unable to contact were sent certified letters informing them they were to be reeducated before returning to work. The DON, ADON and UM revealed a posttest had been given and results reviewed on site with discussion. Interview with RN #2 on 09/17/2021 at 1:36 PM, revealed she received education on the new admission process including assessment and medication and was given a posttest. Interview with LPN #5, on 09/17/2021 at 1:27 PM, revealed she was reeducated regarding the admission process and was given a post test. Interview with LPN #3, on 09/17/2021 at 1:13 PM, revealed she was reeducated on the admission process and was given a posttest. 5. Review of the facility's documentation revealed during morning meeting the IDT reviewed new admissions from the previous day to ensure the admission process was completed, orders verified and medications were available, which started 09/17/2021. Interview with the IDT members, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they reviewed the new admissions to ensure the admission process was completed and medications were available and orders verified. 6. Review of the facility's documentation regarding audits revealed the ED had been reviewing the audit results daily. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she was reviewing audits more often than what was stated in the AOC, she had been reviewing them daily. 7. Review of the facility's documentation revealed the ED/DON were to report the audit results to QAPI weekly. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she had been reviewing the audits and discussing trends and improvements with the QAPI team. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the QAPI had the first meeting today and they reviewed and discussed the last two (2) days of QAPI findings. Interview with the QAPI Committee, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they reviewed the audit results and discussed improvements.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a secure and organized transfer was provided for one (1) of nine (9) sampled residents (Resident #1). The facility failed to provide adequate preparation and direction for Resident #1 in a form and manner he/she could comprehend prior to discharging the resident. Interview and record review revealed prior to Resident #1's admission to the facility, the hospital informed facility staff on 06/30/2021, that the resident had an appointed State Guardian. The facility's care plan for Resident #1 noted interventions which included contacting the resident's Guardian for discharge planning. However, on 07/19/2021, facility staff approached Resident #1 and had the resident sign Against Medical Advice (AMA) paperwork, and subsequently discharged him/her to a homeless shelter via a cab, paid for by the facility. Additionally, the facility failed to ensure the resident was provided discharge education and/or received education related to his/her medications. Additionally, the facility failed to provide Resident #1, who was an insulin dependent Diabetic, with any medications at the time of discharge. Resident #1 presented to a local hospital's Emergency Department (ED) on 07/20/2021, with a blood glucose level of 388 mg/dL (milligrams per deciliter [normal 70-130]) and an elevated potassium level of 6.1 mmol/L (millimoles per liter [normal 3.6 - 5.2]). Resident #1 was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's failure to ensure a safe and orderly transfer has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/03/2021 and was determined to exist on 07/19/2021, at 42 CFR 483.15 Admission, Transfer, and Discharge (F624), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), and 42 CFR 483.40 Behavioral Health Services (F745) at a Scope and Severity of J. The facility was notified of the Immediate Jeopardy on 09/03/2021. The facility submitted an acceptable Allegation of Compliance (AOC) on 09/17/2021 and alleged past noncompliance and removal of immediacy on 07/22/2021. The State Survey Agency validated past noncompliance, as alleged, with removal of immediacy on 07/22/2021. The findings include: Review of the facility's policy entitled, Discharge AMA - Against Medical Advice Guidelines, dated 04/15/2020, revealed the facility encouraged residents to discuss their motivation for wanting to leave and attempt to resolve the resident's concerns. Continued review revealed staff were to inform a resident wanting to discharge AMA, of the possible medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . Per policy review, the facility was to notify the resident's Attending Physician, and responsible party. Further review revealed staff were to also notify the facility's Executive Director (ED), and Director of Nursing (DON). In addition, the facility was to not give medications to a resident wishing to leave AMA without consulting his/her Physician. Review of the facility's policy entitled, Discharge Planning Process, dated 01/10/2018, revealed it was purposeful for the facility to have a discharge planning process which ensured each resident's discharge goals and needs, including care giver support addressed prior to discharge. Continued review revealed a discharge plan of care was to be developed for each resident and it was to be included in the resident's Comprehensive Care Plan (CCP). Per policy, the discharge care plan was to be developed by the facility's Interdisciplinary Team (IDT) with the residents' and/or his/her representative's involvement. Further review revealed the discharge care plan was to address the resident's goals and treatment, identify needs which had to be addressed before the resident could be discharged such as; resident education, rehabilitation, and caregiver support. Per review, the discharge care plan was to identify any post-discharge needs the resident might have, and be reevaluated and updated when the resident's needs or goals changed. The discharge care plan was also to have any referrals made to local agencies documented. Additionally, if the resident wished to be discharged to a setting which did not appear to meet his/her needs, or appeared unsafe the facility was to discuss that information with the resident. Further review revealed the facility was to ensure the risks of being discharged to a place which did not meet the resident's needs was discussed and documented. In addition, the facility was to document discussion with the resident of other suitable options for him/her to discharge to; document any refusals by the resident; and, determine if a referral to Adult Protective Services (APS) was necessary. Record review revealed the facility admitted Resident #1 on 06/30/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) Assessment, dated 07/07/2021, revealed the facility assessed Resident #1 to have moderate cognitive impairment per the Brief Interview for Mental Status (BIMS) examination. Continued review revealed the facility assessed Resident #1 as frequently incontinent of bowel and bladder, to require extensive assistance of one (1) person for: toileting; personal hygiene; and bed mobility. Per review, the facility assessed the resident as totally dependent on staff for bathing, and required the use of a wheelchair for mobility in the facility. Further review revealed the facility assessed Resident #1 to require insulin injections for his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan (CCP) revealed a discharge care plan was initiated on 07/01/2021, for the resident with interventions which included contacting his/her Guardian for the discharge planning. Per review, additional interventions included identifying any equipment needed while the resident resided in the facility, and determining if the resident would need any follow up appointments. Further review of the CCP revealed Resident #1 was care planned as at risk for falls related to weakness, and to require assistance with his/her Activities of Daily Living (ADL's) related to weakness and decreased mobility. In addition, review of the CCP revealed Resident #1 had been care planned as a potential nutritional risk and he/she wandered. Interview with Resident #1's State Appointed Guardian, on 08/23/2021 at 1:04 PM, revealed the resident became a ward of the State under State Guardianship on 07/01/2021. Interview with the hospital's Licensed Clinical Social Worker (LCSW), on 08/24/2021 at 9:12 AM, revealed she had communicated with the facility's Liaison #2 via text message in regards to Resident #1 being in transition from having a family member as Guardian to having a State Appointed Guardian. The LCSW stated Resident #1 still had a Guardian. Review of the documentation provided by the hospital's LCSW, on 09/03/2021, revealed the LCSW had communicated with the facility's Liaison #2 on 06/25/2021, regarding Resident #1's Guardian information. Further review revealed the LCSW had communicated with Liaison #2 again on 06/30/2021, confirming Resident #1's Guardianship status, with a notation of Liaison #2 replying with a confirmation of receiving the information. Interview with the facility's Liaison #2, on 08/25/2021 at 9:04 AM, revealed she was in frequent communication with the hospital LCSW regarding Resident #1 prior to the resident's admission. Continued interview revealed she had received the hospital documentation regarding Resident #1. However, she never received any Guardianship paperwork from the hospital's LCSW. Further interview revealed she was unable to recall the hospital's LCSW sharing any information regarding Resident #1's Guardianship status with her. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the Order revealed Resident #1's prescribed medications included: [MEDICATION(S)] (antihypertensive), [MEDICATION(S)] (for behaviors), [MEDICATION(S)] (for Dementia), [MEDICATION(S)] (anticoagulation), Insulin [MEDICATION(S)] (Diabetes injection medication), [MEDICATION(S)] (antihypertensive), Insulin [MEDICATION(S)] (Diabetes injection medication), [MEDICATION(S)] (for Dementia), [MEDICATION(S)] (antihypertensive), [MEDICATION(S)] (for chest pain), [MEDICATION(S)] (diuretic), and [MEDICATION(S)] (for Depression). Review of Resident #1's Progress Note, dated 07/12/2021 at 3:17 PM, revealed a seventy-two (72) hour meeting had been held which included Resident #1, Therapy staff and the Social Services Director (SSD) to discuss the resident's discharge plan while he/she was residing in the facility. Continued review revealed documentation that noted Resident #1 needed to stay in the facility for at least two (2) more weeks to continue to improve and gain more independence. Per the Progress Note, Resident #1 required cues from staff regarding safety awareness before transfers to avoid falling. Further review revealed Resident #1 was unable to transfer out of his/her wheelchair to stand during the meeting. Record review revealed Resident #1 asked the staff present if he/she could stay and continue to work with Therapy to improve in transferring, gain more Activities of Daily Living (ADL) independence and improve his/her continence. Additional review of the Progress Notes revealed a Note dated 07/17/2021, documented by Licensed Practical Nurse (LPN) #5, who noted that Resident #1 had been found in another resident's room rummaging through that resident's belongings. Continued review revealed when staff redirected Resident #1 from the other resident's room, he/she tried to enter the other resident's room again shortly after being redirected. Further review of the Note revealed the DON was notified and Resident #1 was placed on 1:1 supervision. Interview with LPN #5, on 08/25/2021 at 1:43 PM, revealed the Aide had notified her of Resident #1 being in another resident's room, and had tried to reenter the room after being redirected by staff. Interview revealed the incident happened on a Saturday, and staff telephoned (phoned) the DON, who was the Manager on duty that day regarding the incident. LPN #5 stated the DON had instructed staff to place Resident #1 on 1:1 supervision, and that on Monday (this incident happened on a Saturday) the facility would go from there. Review of the Discharge Note for Resident #1, dated 07/19/2021 at 11:43 AM, completed by LPN #3, revealed no documented evidence of discharge education, or education related to the resident's medications having been provided for the resident prior to discharge. Further review of the Discharge Note revealed no documented evidence of any Durable Medical Equipment (DME) having been sent with Resident #1 when the facility discharged him/her. Additionally, there was no documented evidence the facility supplied Resident #1 with needed supplies such as incontinence products, food items or any monetary way to purchase those items. Review of the hospital records (after discharge from the facility), dated 07/20/2021, revealed Resident #1 presented to the hospital ED with a blood glucose of 388 and a potassium of 6.1. Continued review revealed Resident #1 was hospitalized and diagnosed with [CONDITION(S)] (high blood sugar), [CONDITION(S)] (high potassium), and leg pain, secondary to lack of having medications to take for his/her health conditions. Interview with Resident #1, on 09/02/2021 at 8:50 AM, revealed when he/she left the faciity on [DATE], the resident was not provided any education regarding his/her medications. Further interview revealed the facility had not provided the resident with any money to purchase care supplies he/she might have needed. Interview with the Social Services Director (SSD), on 08/24/2021 at 9:18 AM, revealed she had been present at the facility's morning meeting on 07/19/2021, when the DON stated Resident #1 was leaving the facility AMA that day. The SSD stated she voiced her concerns to the DON that she believed Resident #1 was not safe to discharge due to the resident requiring a personal wheelchair which he/she did not have. Continued interview revealed the DON told her to give Resident #1 a facility wheelchair and let the resident go on and leave. The SSD stated she notified LPN #3, after her discussion with the DON, to review the AMA paperwork with Resident #1 and have him/her ready for discharge. She stated she had worked in the facility for over twenty (20) years and calling the Physician had always been a standard for any resident wanting to leave AMA. According to the SSD, she approached LPN #3 and asked if Resident #1 was ready for discharge and the nurse replied yes, so she assumed the Physician had been notified. Further interview revealed she witnessed the AMA paperwork and along with LPN #3, set up transportation via a cab and discharged Resident #1 to a homeless shelter. Additionally, she stated after Resident #1 left the facility, she notified Adult Protective Services (APS) as she felt the resident's discharge was unsafe. Interview with the Assistant Director of Nursing (ADON), on 08/25/2021 at 3:23 PM, revealed the facility's discharge planning process was initiated on a resident's admission and usually the SSD lead the discharge process to ensure the resident had all he/she needed. The ADON stated the facility had a conversation regarding Resident #1 and potentially finding placement for him/her at another more suitable facility related to his/her wandering. Continued interview revealed during the facility's morning meeting on 07/09/2021, the DON stated Resident #1 had to go because he/she had been found over the weekend in another resident's room stealing that resident's things. She stated she believed the Physician had not been notified prior to Resident #1's AMA discharge, and there was no documentation in the resident's record noting the Physician had been notified. Interview revealed she had performed a review of Resident #1's medical records and noticed the morning of Resident #1's discharge day, his/her blood sugar was greater than 400, with no documentation noting the Physician had been notified of that information. The ADON further revealed with a blood sugar that high, Resident #1 could have become confused, and she thought the homeless shelter Resident #1 was discharged did not provide medical care. Interview with LPN #2, on 08/25/2021 at 11:06 AM, revealed it was important for residents to experience a safe discharge. Per interview, it was also important for staff to ensure residents being discharged were properly educated regarding their medications. LPN #2 stated for a resident being discharged staff should check his/her ambulation status, and identify any potential safety concerns. Further interview revealed while educating the resident prior to discharge was important, it was also crucial for staff to ensure the resident could comprehend and understand the education being provided. Interview with LPN #3, on 09/03/2021 at 10:00 AM, revealed she had gone over the AMA paper work with Resident #1 on 07/19/2021. She stated she had been instructed that everything else had been completed, and she just needed to review the AMA paperwork with Resident #1. Continued interview revealed it was important to notify the Physician regarding a resident wanting to leave AMA, as the Physician might give additional orders and could give the okay for allowing the resident to leave with his/her medications. Additionally, she revealed Resident #1 had not left the facility with any medications on the day of discharge, and that was why she had explained to the resident the importance of following up with a Primary Care Physician after discharge. Interview with LPN #4, on 08/23/2021 at 2:45 PM, revealed when a resident wished to leave AMA, the Physician was to be notified because he may give proper discharge orders and allow the resident to leave with his/her medications. She revealed it was important for residents to have a safe discharge which ensured the residents remained out of harm's way once they left the facility. Additionally, she stated she believed there had been a better place for Resident #1 to have been discharged to besides the homeless shelter. Interview with LPN #5, on 08/25/2021 at 1:43 PM, revealed she was Resident #1's assigned nurse on 07/19/2021. She stated during her morning medication pass she did not recall Resident #1 coming to her and expressing wishes to leave the facility AMA. Continued interview revealed the LPN was pulled to another unit around 9:00 AM and when she returned to the unit where Resident #1 resided at 4:00 PM, she was informed Resident #1 had left the facility AMA that morning. She further revealed Resident #1 leaving AMA was not safe due to his/her history of blood clots, and the resident was not capable of transferring himself/herself safely. LPN #5 stated Resident #5 required assistance with transfers. Interview with the facility's previous DON, on 08/25/2021 at 1:27 PM, revealed during Resident #1's stay at the facility, he/she had mentioned leaving prior to being discharged AMA on 07/19/2021. Per interview, staff were able to deescalate the resident previously when he/she spoke of leaving the facility AMA. The DON stated she explained to Resident #1 why it was important that he/she stayed in the facility. Continued interview revealed in the facility's morning meeting on Monday, 07/19/2021, she had notified the SSD of Resident #1 expressing his/her wishes to leave AMA that day. The previous DON stated she believed the SSD was in charge of discharge planning and the discharge care plan. Further interview revealed she was notified by the ADON of LPN #3 notifying the Physician prior to Resident #1 leaving AMA. Additionally, interview revealed Resident #1 was adamant that he/she was admitted to the facility with his/her own wheelchair, so the facility allowed the resident to take the wheelchair he/she had used while residing in the facility. Further interview revealed the facility also gave Resident #1 a list of his/her currently prescribed medications; however no medications were given to the resident. The DON further revealed after Resident #1 was discharged from the facility, the SSD notified APS due to her concerns that the resident's discharge was not safe. Interview with the previous Executive Director (ED), on 08/26/2021 at 4:30 PM, revealed she was not in attendance at the facility's morning meeting on 07/19/2021. She stated no one made her aware Resident #1 was discharged AMA until after the resident had already left the facility. Continued interview revealed per the facility's policy, she should have been notified prior to Resident #1 being discharged AMA in order for her to attempt to resolve any concerns the resident had. Per interview, if she had been able to resolve Resident #1's concerns, he/she might have stayed at the facility. The former ED stated residents' discharge plans started on admission and the SSD and clinical team lead the discharge planning. Further interview revealed it was important that the facility ensured a safe discharge for residents in order for them to be safe, and prevent any re-hospitalization s. In addition, she stated she expected facility staff to make proper notifications as required, and follow the facility's policy regarding AMA discharges. She further revealed the Physician was to be notified of a resident discharging AMA. Interview with the Medical Director, on 09/03/2021 at 1:45 PM, revealed he was notified when Resident #1 requested to leave AMA; however, he had not provided facility staff with any further orders. He stated Resident #1 had been alert and oriented, and the facility had not been aware the resident had a Guardian. Interview with the SSD, on 09/03/2021 at 2:56 PM, revealed discharge planning was initiated on a resident's admission to the facility. Per interview, the goal was for the best possible outcome for a new resident. She stated it was important after being discharged for the resident to maintain their goals in order for them to remain safe. Additionally, she revealed it was never the facility's goal to discharge Resident #1 to an unsafe place because something adverse could potentially happen to the resident. Interview with the facility's current Acting DON, on 09/03/2021 at 2:01 PM, revealed the facility's discharge process began on a resident's admission, and was to be reviewed regularly with the IDT. Additional interview revealed the facility's goal was resident safety when discharging from the facility, and for the resident being discharged to have everything they needed to be successful after discharge. Interview with the facility's current ED, on 09/03/2021 at 3:23 PM, revealed the IDT and SSD were supposed to be working closely together to ensure safe discharges for all residents. She revealed residents wanting to leave AMA were to be educated on the risks and the potential of losing out on services after they left the facility. Per interview, it was the facility's responsibility to ensure a resident was safely discharged . Further interview revealed if a resident wished to leave the facility AMA, the facility could not ensure that certain needs of the resident were obtained. The facility alleged it implemented the following actions to remove immediacy: 1. Regional Vice President of Operations (RVPO) and Vice President of Clinical Services (VPCS) reeducated the Interdisciplinary Team (IDT) which included the Executive Director (ED), Director of Nursing (DON), Social Services Director (SSD) Dietary Manager (DM), Maintenance Director, Therapy Director, Activity Director Assistant Director of Nursing (ADON), Human Resources Director (HR), Scheduler, Minimum Data Set (MDS) Coordinator, Assistant Housekeeping Director, and Admission Director on 07/20/2021. The education included Against Medical Advice (AMA) Policy, AMA form, and the policy on Change in a Resident's Condition/Status (CIC) which included discharge without proper medical authority and care plan revisions to ensure a safe discharge with a posttest administered. 2. On 07/21/2021, the RVPO and VPCS completed an audit on all current residents to ensure guardian status paperwork was in the medical record. 3. On 07/21/2021, the RVPO and VPCS completed an audit of all discharges from 06/01/2021 through 07/21/2021 to ensure proper discharge notification based on guardianship status. 4. The ED, DON, and SSD are no longer employed at the facility effective 07/21/2021. 5. Newly hired management members such as the ED, DON and SSD received education regarding care plan and discharge processes that included CIC, discharge without proper medical authority and care plan revision, with a posttest. 6. When hired, the new SSD will receive education related to ensuring when residents were discharge they were provided with sufficient medical related social services. 7. Beginning 07/21/2021, any new admissions will be audited by the IDT for guardianship status and discharge care planning five (5) days week for (6) months. 8. The ED and/or DON will review results of the audits daily. 9. The ED, DON, and/or SSD will submit results of the audit findings weekly x 6 months to the Quality Assurance Performance Improvement (QAPI) Committee which is the IDT until the issue is resolved. The State Survey Agency (SSA) validated the removal plan by: 1. Record review revealed reeducation was provided to the IDT team with a posttest provided with a completion score of 100% to all IDT members. Interview with the IDT, on 09/17/2021 at 10:09 AM, 10:15 AM and 10:35 AM, revealed they received educations regarding the AMA policy and the form along with discharge procedures for someone wanting to leave AMA along with the care plan updates to ensure a safe discharge. 2. Record review revealed on 07/21/2021, Resident #1's care plan was updated to reflect guardianship status. Interview with the MDS Coordinator on 09/147/2021 at 12:33 PM, revealed she updated Resident #1's care plan to reflect his/her guardianship status. 3. Record review revealed on 07/21/2021 the RVPO and VPCS completed an audit of all discharges from 06/01/2021 through 07/21/2021 to ensure proper notification based on guardianship status. Interview with the Regional Vice President of Operations (RVPO), on 09/17/2021 at 9:20 AM, revealed she completed the audit to ensure no one was missed and to make sure they had any current in house guardianships that they were reflected on the medical record. Interview with the Vice President of Clinical Services (VPCS), on 09/17/2021 at 2:33 PM, revealed she assisted with audits and reviewed any guardianship discharges to ensure proper notifications were made. 4. Interview with the previous ED, DON and SSD revealed they are no longer employed at the facility. 5. Record review revealed newly hired management members, the ED DON and SSD received educations on care plans and the discharge process. Interview with the ED and DON, on 09/17/2021 at 2:06 PM, revealed she completed education on day of hire and completed a posttest that was reviewed and any question were discussed. 6. Interview with the SSD, on 09/17/2021 at 12:35 PM, revealed she completed education upon hire regarding care plan revisions and discharge processes and completed a posttest with discussion afterward. 7. Record review revealed audits were completed starting 07/21/2021 on new admissions for guardianship status and discharge care planning. Interview with the IDT, on 09/17/2021 at 10:09 AM, 10:15 AM and 10:35 AM, revealed new admissions were being reviewed in the clinical meetings to review for guardianship status and discharge care plans. 8. Record review of the audit revealed the ED has been reviewing the audit results daily. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she reviewed audits daily. 9. Record review revealed the ED/DON reported the audit results to QAPI weekly. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she has been reviewing the audits and discussing trends and improvements with the QAPI team. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the QAPI meeting had been discussing trends and improvements based on the audit findings. Interview with the QAPI Committee, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they reviewed the audit results and discussed improvements.

Based on interview, record review and facility policy review, it was determined the facility failed to implement the Comprehensive Person-centered Care Plan for one (1) of nine (9) sampled residents (Resident #1). The facility admitted Resident #1 on 06/30/2021. Resident #1 had a State Appointed Guardian. Resident #1's Discharge Care Plan which was initiated on 07/01/2021, had interventions that included for staff to contact guardian for discharge planning. The facility approached Resident #1 and had the resident sign Against Medical Advice (AMA) paperwork. The facility discharged Resident #1 on 07/19/2021 to a local homeless shelter. The facility failed to implement Resident #1's care plan intervention to contact his/her Guardian for discharge planning. The facility's failure to implement a comprehensive person-centered care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/03/2021 and was determined to exist on 07/19/2021, at 42 CFR 483.15 Admission, Transfer, and Discharge (F624), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), and 42 CFR 483.40 Behavioral Health Services (F745) at a Scope and Severity of J. The facility was notified of the Immediate Jeopardy on 09/03/2021. The facility submitted an acceptable Allegation of Compliance (AOC) on 09/17/2021 and alleged past noncompliance and removal of immediacy on 07/22/2021. The State Survey Agency validated past noncompliance, as alleged, with removal of immediacy on 07/22/2021. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 01/13/2018, revealed the purpose of the policy was to ensure the provision of services to enable residents to live with dignity. Per review, the policy's purpose also included supporting the resident's goals, choices, and preferences including goals related to their daily routines. The Comprehensive Care Plan described the services furnished were to help resident's attain, or maintain his/her highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's medical record revealed the facility admitted the resident on 06/30/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) Assessment, dated 07/07/2021, revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was moderately cognitively impaired. Continued review revealed the facility assessed Resident #1, with the expectation of being discharged to the community when appropriate, with no referrals needed. The State Survey Agency (SSA) Surveyor requested the facility provide a Comprehensive Care Plan (CCP) with revisions for Resident #1 on 07/27/2021. Review of the CCP provided revealed the facility had initiated a Discharge Care Plan on 07/01/2021 for Resident #1, with the focus of Discharge Plan is Homeless Program for Housing. Further review revealed the interventions initiated on 07/01/2021 included: Contacting the Guardian for discharge planning; identify equipment needed while residing in the facility; and, identifying whether the resident needed any follow up appointments. Review of the Progress Notes, dated 07/19/2021, revealed Resident #1 left AMA from the facility at 11:00 AM. Continued review revealed no documented evidence the State Appointed Guardian for Resident #1 was notified as per the care plan interventions. Per review, there was no documented evidence Resident #1 was educated prior to his/her discharge on 07/19/2021. Additionally, there was no documented evidence the facility supplied Resident #1 with needed supplies such as incontinence products, food items or any monetary way to purchase those items. Interview with Licensed Practical Nurse (LPN) #4, on 08/23/2021 at 2:45 PM, revealed the care plan was a plan which described each individual resident's needs. She stated it was important to follow residents' care plans and interventions, to ensure the residents were receiving the appropriate care. Further interview revealed if residents' care plan interventions were not followed, staff could not be sure they were giving the residents the right care. Interview with the facility's previous Director of Nursing (DON), on 08/25/2021 at 1:27 PM, revealed a resident's care plan was a person centered plan on how the facility could meet the resident's needs and help them achieve their goals. She stated it was important staff implemented residents' care plan interventions to ensure residents received the proper care they required. Further interview revealed if staff did not follow and implement residents' care plan interventions, the residents would not receive the necessary care and services they required. She further stated she was not aware Resident #1's Discharge Care Plan stated to contact his/her Guardian prior to discharge. Interview with the previous Executive Director (ED), on 08/26/2021 at 4:30 PM, revealed she expected her staff to follow all residents' care plans and implement the interventions to ensure residents received the necessary goods and services they required. The facility alleged it implemented the following actions to remove immediacy: 1. Regional Vice President of Operations (RVPO) and Vice President of Clinical Services (VPCS) reeducated the Interdisciplinary Team (IDT) which included the Executive Director (ED), Director of Nursing (DON), Social Services Director (SSD) Dietary Manager (DM), Maintenance Director, Therapy Director, Activity Director Assistant Director of Nursing (ADON), Human Resources Director (HR), Scheduler, Minimum Data Set (MDS) Coordinator, Assistant Housekeeping Director, and Admission Director on 07/20/2021. The education included Against Medical Advice (AMA) Policy, AMA form, and the policy on Change in a Resident's Condition/Status (CIC) which included discharge without proper medical authority and care plan revisions to ensure a safe discharge with a posttest administered. 2. On 07/21/2021, the RVPO and VPCS completed an audit on all current residents to ensure guardian status paperwork was in the medical record. 3. On 07/21/2021, the RVPO and VPCS completed an audit of all discharges from 06/01/2021 through 07/21/2021 to ensure proper discharge notification based on guardianship status. 4. The ED, DON, and SSD were no longer employed at the facility effective 07/21/2021. 5. Newly hired management members such as the ED, DON, and SSD received education regarding care plan and the discharge process to include CIC, discharge without proper medical authority and care plan revision, with a posttest. 6. Beginning 07/21/2021, any new admissions were to be audited by the IDT for guardianship status and discharge care planning five (5) days week for six (6) months. 7. The ED and/or DON were to review results of the audits daily. 8. The ED, DON, and/or SSD were to submit results of the audit findings weekly times (x) six (6) months to the Quality Assurance Performance Improvement (QAPI) Committee which is the IDT until the issue is resolved. The State Survey Agency (SSA) validated the removal plan by: 1. Review of facility documentation revealed reeducation was provided to the IDT team with a posttest provided and a completion score of 100% to all IDT members. Interview with the IDT, on 09/17/2021 10:09 AM, 10:15 AM and 10:35 AM, revealed they received education regarding the AMA policy and the form along with discharge procedures for someone wanting to leave AMA along with the care plan updates to ensure a safe discharge. 2. Record review revealed on 07/21/2021, Resident #1's care plan was updated to reflect guardianship status. Interview with the MDS Coordinator on 09/17/2021 at 12:33 PM, revealed she updated Resident #1's care plan to reflect his/her guardianship status. 3. Review of the facility's documentation revealed on 07/21/2021, the Regional Vice President of Operations (RVPO), and Vice President of Clinical Services (VPCS) completed an audit of all discharges from 06/01/2021 through 07/21/2021 to ensure proper notification based on guardianship status. Interview with the RVPO, on 09/17/2021 at 9:20 AM, revealed she completed the audit to ensure no one was missed and to make sure they had any current in house guardianships that they were reflected on the medical record. Interview with the VPCS, on 09/17/2021 at 2:33 PM, revealed she assisted with audits and reviewed any guardianship discharges to ensure proper notifications were made. 4. Interview with the previous ED, DON and SSD revealed they were no longer employed at the facility. 5. Review of facility documentation revealed newly hired management members, the ED, DON and SSD received educations on care plans and the discharge process. Interview with the ED and DON, on 09/17/2021 at 2:06 PM, revealed she completed education on day of hire and completed a posttest that was reviewed and any questions were discussed. 6. Review of facility documentation revealed audits were completed starting 07/21/2021 on new admissions for guardianship status and discharge care planning. Interview with the IDT, on 09/17/2021 at 10:09 AM, 10:15 AM and 10:35 AM, revealed new admissions were being reviewed in clinical meeting to review for guardianship status and discharge care plans. 7. Review of facility documentation of the audits revealed the ED had been reviewing the audit results daily. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she was reviewing the audits daily. 8. Review of facility documentation revealed the ED/DON were to report the audit results to QAPI weekly. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she had been reviewing the audits and discussing trends and improvements with the QAPI team. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the QAPI meeting had been discussing trends and improvements based on the audit findings. Interview with the QAPI Committee, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they reviewed the audit results and discussed improvements.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the provision of pain management for one (1) of nine (9) sampled residents (Resident #2). The facility admitted Resident #2 on 04/17/2021, with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to complete any pain assessments while Resident #2 was admitted and failed to administer the PRN pain medication after the resident requested it. Prior to admission to the facility, Resident #2 had several surgeries on his/her buttocks while in the hospital, which the resident stated caused him/her constant pain. Approximately twelve (12) hours after being admitted to the facility, Resident #2 requested to be sent back to the acute care hospital related to unrelieved pain. Review of the hospital record revealed the hospital administered [MEDICATION(S)] (an opioid used to treat moderate to severe pain). The facility's failure to provide pain management has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/2021 and was determined to exist on 04/17/2021. Immediate Jeopardy was determined to exist at CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), CFR 483.25 Quality of Care (F697) at a Scope and Severity of J. The facility was notified of the Immediate Jeopardy on 09/13/2021. The facility submitted an acceptable Allegation of Compliance (AOC) on 09/17/2021 and alleged removal of immediacy on 09/17/2021. The State Survey Agency validated removal on 09/17/2021, as alleged. Furthermore, on 09/17/2021, the State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 09/17/2021, prior to exit on 09/17/2021, with remaining non-compliance at 42 CFR 483.25 Quality of Care, Pain Management (F697) at a S/S of D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Pain Assessment and Management, revised 03/2020, revealed the policy was to assist staff with identifying a resident's pain. Per review, the policy was also to assist in developing interventions which were consistent with the resident's goals and needs and address the underlying cause of his/her pain. Continued review revealed the policy defined pain management as the process of alleviating a resident's pain based on his/her clinical condition and established treatment goals. The policy stated the facility's pain management program was based on its commitment to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Continued review of the policy revealed staff were to complete comprehensive pain assessments upon a resident's admission to the facility and a resident's acute pain was to be assessed every thirty (30) to sixty (60) minutes after the onset using a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. Further review revealed staff were to document the resident's reported pain level after assessing him/her. The policy further revealed staff were to reassess the resident's pain as indicated until the resident achieved pain relief, and were to ensure all assessment/reassessment information was recorded in his/her medical record. Review of the facility's policy, Preparation for Medication Administration, revised 12/14/2015, revealed when staff administered PRN medications they were to document the date and time, dose and route of administration. Further review revealed staff were also to document the resident's complaints or symptoms at the time of administration, and note whether the pain medication was effective. In addition, staff were to ensure they documented their signature/initials when recording the pain medication administration. Review of Resident #2's medical record revealed the facility admitted him/her on 04/17/2021 via ambulance at approximately 12:15 PM. Per review Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed staff entered Resident #2's information into the facility's Electronic Health Record (EHR) system at 2:05 PM on the day of admission. Further review revealed Resident #2 resided in the facility for approximately twelve (12) hours. Review of the hospital record revealed the hospital admitted Resident #2 to the emergency department on 04/18/2021 and administered [MEDICATION(S)] and began intravenous (IV) administration of an antibiotic. Review of the hospital Discharge Summary, dated 04/16/2021, revealed Resident #2 was admitted to the hospital on 04/03/2021 with sharp/aching constant non-radiating pain which worsened with movement. Per review, Resident #2 had rated his/her pain as a ten (10) out of a possible ten (10) on the pain scale, which was the worst pain level. Continued review of the Discharge Summary revealed Resident #2's discharge medication list included [MEDICATION(S)] (a narcotic pain medication) 10-235 milligram (mg), one (1) tablet by mouth (PO) every four (4) hours as needed (PRN) for pain. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed an order, entered into Resident #2's EHR on 04/17/2021 at 5:34 PM, for staff to Monitor Pain and Document the resident's pain level every shift. Review of Resident #2's Medication Administration Record (MAR), dated 04/2021, revealed no documented evidence of the resident's PRN [MEDICATION(S)] pain medication having been administered while he/she resided in the facility for the twelve (12) hours. Continued review of the MAR revealed no documented evidence of staff noting they had monitored and documented Resident #2's pain level every shift as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Assessments noted in Resident #2's Medical Record revealed no documented evidence a pain assessment was completed for the resident after admittance to the facility on [DATE]. In addition, review revealed no documented evidence of pain assessments noted prior to Resident #2 being sent back to the hospital on 04/18/2021, due to his/her unrelieved pain. Interview with Resident #2, on 09/02/2021 at 11:54 AM, revealed staff had not even recognized he/she was living in the facility until four (4) or five (5) hours after being admitted , when he/she had to walk down the hallway to inquire about his/her meals and medications. Continued interview revealed Resident #2 had several surgeries performed on his/her buttock due to an abscess. Resident #2 stated staff had said his/her pain medications would not be delivered to the facility until 2:00 AM on 04/18/2021, greater than twelve (12) hours after his/her admission. Further interview revealed Resident #2's pain was constant and it hurt to use the restroom, lay down or do pretty much anything due to the wound on his/her buttock. In addition, Resident #2 stated he/she had not received any pain medication after leaving the hospital on 04/17/2021, and he/she was in pain. Review of the facility's Emergency Drug System Inventory documentation located in the Medication Room revealed three (3) [MEDICATION(S)] 10-325 mg tablets were available on 04/17/2021 for administration to Resident #2. Further review revealed attempts were made to retrieve the pain medication from the Emergency Drug System; however, they were unsuccessful. Continued review revealed Certified Medical Technician (CMT) #1 accessed the Emergency Drug System and attempted to pull the [MEDICATION(S)] 10-325 mg tablet from the system but skipped the medication which was not pulled or administered to Resident #2. Interview with the Data Entry Technician from the facility's Provider Pharmacy, on 09/07/2021 at 10:50 AM, revealed when a new resident's admission medication orders were entered into the facility's EHR system, the Pharmacy was notified of the admission and their medications. She stated orders for medications not available in the facility's Emergency Drug Kit, which were due before the Pharmacy's normal delivery time, were sent STAT (immediately) to a local back-up twenty-four (24) hour Pharmacy to be filled and delivered. Per interview, that process ensured facility staff had the medications required and prevented a delay in administration. Continued interview revealed the Pharmacy received Resident #2's first medication orders on 04/17/2021 at 6:24 PM. The Data Technician revealed [MEDICATION(S)] 10-325 was available in the facility's Emergency Drug System for administration. According to the Data Technician, the Pharmacy had documentation noting the drawer in which the [MEDICATION(S)] medication was stored in the facility's Emergency Drug System had been pulled open; however, an actual tablet was not removed from the system drawer and administered per the documentation. Further interview revealed the pain medication was skipped for some reason, but there was nothing which showed the Pharmacy why the medication was skipped. Interview with the facility's Pharmacy's Office Manager, on 09/08/2021 at 9:35 AM, revealed when the Emergency Drug System was fully stocked, it contained six (6) of the [MEDICATION(S)] 10-325 mg tablets. He stated he was unable to go back to 04/17/2021, and review how many tablets of the pain medication were actually available in the facility's Emergency Drug System. He revealed if the system had not had any of the [MEDICATION(S)] available to pull it would notify the staff person making the attempt and denied them access to the drawer the medication was stored. Further interview revealed if that occurred the medication order would then be sent STAT to the local back-up Pharmacy who would supply the medication. Interview with Licensed Practical Nurse (LPN) #2, on 09/07/2021 at 10:03 AM, revealed she worked the 7:00 PM - 7:00 AM (night) shift at the facility, and had started working there on 04/17/2021, the day Resident #2 was admitted . Per interview, LPN #1 had not informed her of Resident #2's arrival, during the change of shift report. Per interview, when she started her medication pass, she noticed Resident #2's call light was on frequently, and decided to enter his/her room to she if she could assist the resident. She stated upon entering Resident #2's room, his/her main focus was his/her pain and the fact he/she had not had any medications, including pain medications since arriving at the facility. LPN #2 stated she notified the Director of Nursing (DON) regarding Resident #2's request for pain medication and the DON instructed her to call Pharmacy and confirm when the resident's medications were to be delivered. According to LPN #2, she attempted to obtain a dose of [MEDICATION(S)] pain medication from the facility's Emergency Drug System with another staff person as her witness, as controlled medications required a witness. However, she stated she was unsuccessful in her attempt to get the [MEDICATION(S)] medication as the System notified her there were no doses of the medication available to obtain. Further interview revealed if a resident was experiencing pain, such as Resident #2 had been, it could cause adverse effects for the resident like making him/her hypertensive. In addition, she stated at 12:15 AM on 04/18/2021 Resident #2 complained of acute intense abdominal pain and requested to be sent back to the hospital. Interview with CMT #1, on 09/07/2021 at 2:49 PM, revealed she did not recall assisting LPN #2 with attempting to obtain the [MEDICATION(S)] from the facility's Emergency Drug System on 04/17/2021. She stated however, she had access to the Emergency Drug System for obtaining medications for residents when needed. Continued interview revealed sometimes when she attempted to use the facility's Emergency Drug System it would accept her biometrics (measurement and statistical analysis of people's unique physical and behavioral characteristics, such as fingerprints) and other times it would not, so she was unable to have consistent access to the system. The Surveyor attempted a telephone (phone) interview with Licensed Practical Nurse (LPN) #1 and Certified Nurse Assistant (CNA) #1, who had both been assigned to Resident #2's care on the day of admission. However, all attempts were unsuccessful. Interview with the Executive Director on 09/10/2021 at 2:32 PM, revealed LPN #1 and CNA #1 were no longer were employed by the facility. Interview with the former Director of Nursing (DON), on 09/13/2021 at 9:50 AM, revealed staff should have faxed Resident #2's face sheet and medication orders to the Pharmacy to ensure his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated pain medication needed to be administered as ordered and requested by the resident. Interview with the former Executive Director (ED), on 09/10/2021 at 1:31 PM, revealed her expectations for a newly admitted resident's medications was for the medications to be available for administration upon his/her admission. Continued interview revealed the facility had processes in place to ensure medications were available for administration to a resident. Per interview, she stated she expected Resident #2 would have received his/her pain medication upon requesting it. The former ED further revealed if the pain medication had not been available she would have expected staff to pull the medication from the facility's Emergency Drug System or have the medication order sent STAT to the local backup Pharmacy. Interview with the Medical Director, on 09/13/2021 at 10:36 AM, revealed his expectations were for staff to administer pain medication as ordered. Per interview, if staff failed to do so, the resident might experience uncontrolled pain. Interview with the current ED, on 09/10/2021 at 2:32 PM, revealed she expected staff to use the facility's processes which were in place in order to ensure all residents received the things they needed, such as pain medication. The facility alleged it implemented the following actions to remove immediacy: 1. Resident #2 no longer resided in the facility. 2. The ED and DON, notified the Physician of the event and held an ADHOC QAPI meeting on 09/13/2021 to discuss the event and the development of an action plan. 3. The DON/Licensed Nurses completed pain assessments on current residents on or before 09/16/2021. 4. The DON, ADON, UM and/or VPCS reeducated all licensed staff, including agency, by 09/16/2021, regarding pain management to include pain assessments, administering pain medication, and the process for obtaining pain medication from the emergency medication system with a posttest of 100%. Staff not available were reeducated upon return to work. New hires were to be educated in orientation. 5. The facility's Interdisciplinary Team (IDT) was to review all residents in clinical meetings to ensure their pain was managed, pain was assessed and pain medications were available starting 09/17/2021, daily for two (2) weeks. 6. The ED and/or DON were to review audit results weekly for four (4) weeks. 7. The ED and/or DON were to report their findings weekly to the QAPI Committee. The State Survey Agency (SSA) validated the removal plan by: 1. Record review revealed Resident #2 was discharged on [DATE] and was no longer residing in the facility. 2. Review of the facility's documentation revealed an ADHOC meeting was held on 09/13/2021, with the ED, DON, and Physician in attendance. Interview with the ED, DON, and Physician on 09/17/2021, revealed during the ADHOC meeting, the survey findings were discussed and steps were identified to take to lift the immediacy and ensure the identified concerns would not reoccur. 3. Record review revealed pain assessments were completed every shift and documented on the Medication Administration Record (MAR) by the floor nurses on or before 09/16/2021 and were continued. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the DON and ED audited to ensure all residents had pain assessments every shift. She stated those assessments were reviewed every day to ensure residents' pain was managed, pain interventions were effective and the pain medications were available. 4. Review of facility documentation revealed education was provided to all licensed staff on or before 09/16/2021, with a posttest. Continued review revealed certified letters were mailed to employees who had not yet received the education. Interview with the DON, ADON, and Unit Manager (UM), on 09/17/2021, revealed they completed education with licensed staff. Per interview, those staff unable to be reached to come in for the education were sent certified letters, telling them were to be reeducated before returning to work. The DON, ADON and UM stated a posttest was given and reviewed on site with discussion of any concerns/issues. Interview with RN #2 on 09/17/2021 at 1:36 PM, revealed she received education on pain management including assessments, and administering pain medication and was given a posttest. Interview with LPN #5, on 09/17/2021 at 1:27 PM, revealed she was reeducated regarding pain management and assessments and given a posttest. Interview with LPN #3, on 09/17/2021 at 1:13 PM, revealed she was reeducated on pain medication and pain assessments and had a posttest. 5. Review of facility documentation revealed during the facility's clinical meeting the IDT reviewed all residents' pain assessments for completion and to ensure pain medications were available and given as ordered starting on 09/17/2021. Interview with the IDT members, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they had reviewed pain management of all residents to ensure their pain medications were available and assessments were completed. 6. Review of the audit documentation revealed the ED had been reviewing the audit results daily. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she was reviewing audits more often than what was stated in the facility's Allegation of Compliance (AOC). She stated she had been reviewing them daily. 7. Review of the facility's documentation revealed the ED/DON was to report the audit results to the QAPI Committee weekly. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she had been reviewing the audits and discussing trends and improvements with the QAPI team. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the QAPI Committee had the first meeting that day and had reviewed and discussed the last two (2) days of QAPI findings.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure medically related Social Services were provided to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one (1) of nine (9) sampled residents (Resident #1). Interview and record review revealed the facility's Social Services Director (SSD) had been attempting to have Resident #1 transferred to a sister (facilities that are part of the same corporation) facility. However, the facility initiated an Against Medical Advice (AMA) discharge for Resident #1, on 07/19/2021 at the insistence of the facility's Director of Nursing (DON). The SSD felt the resident's discharge was not safe; however, the facility discharged Resident #1, an insulin dependent diabetic, to a local homeless shelter without the resident's medications which included his/her insulin. The facility failed to ensure the resident received the medically related Social Services he/she required for safety. After discharge to the homeless shelter, Resident #1 presented to the hospital on 07/20/2021, with a blood glucose level of 388 mg/dL (milligrams per deciliter), the normal range for an adult was between 70 and 130 mg/dL before meals; and a Potassium level of 6.1 mEq/L (milliequivalents per liter), the normal range for adults was 3.7 to 5.2 mEq/L. The facility's failure to ensure medically related Social Services was provided has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/03/2021 and was determined to exist on 07/19/2021, at 42 CFR 483.15 Admission, Transfer, and Discharge (F624), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), and 42 CFR 483.40 Behavioral Health Services (F745) at a Scope and Severity of J. The facility was notified of the Immediate Jeopardy on 09/03/2021. The facility submitted an acceptable Allegation of Compliance (AOC) on 09/17/2021 and alleged past noncompliance and removal of immediacy on 07/22/2021. The State Survey Agency validated past noncompliance, as alleged, with removal of immediacy on 07/22/2021. The findings include: Review of the Social Services Director's (SSD) Job Description, undated, revealed the SSD ensured residents and families were assisted with personal and environmental difficulties which predisposed them to illness or interfered with obtaining maximum benefits of their medical care. Continued review revealed the SSD assisted with the following: provision of transfer services for residents; evaluation of residents for discharge potential; provision of comprehensive discharge planning services; coordination of post discharge care and services; and, preparation of the discharge summaries. Record review revealed the facility admitted Resident #1 on 06/30/2021, with diagnoses that included [CONDITION(S)], Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Muscle Weakness, Dysphagia, Anxiety, Unsteadiness, Depression, and Hypertension. Interview with Resident #1's State Appointed Guardian (SAG), on 08/23/2021 at 1:04 PM, revealed she became Resident #1's Guardian on 07/01/2021. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have moderate cognitive impairment as indicated by the Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15). Continued review revealed the facility assessed Resident #1 to be frequently incontinent of bowel and bladder. Further review revealed the facility assessed Resident #1 to require insulin injections for his/her diagnosis of Type 2 DM. In addition, the facility assessed the resident as receiving numerous medications to treat his/her other diagnoses. Review of Resident #1's Comprehensive Care Plan (CCP) revealed the facility initiated a discharge care plan for the resident on 07/01/2021, with interventions which included for staff to contact his/her Guardian for discharge planning. Continued review of the discharge care plan revealed staff were to identify any equipment Resident #1 needed while in the facility and determine if the resident would need any follow up appointments. Continued review of the CCP revealed the facility had care planned Resident #1 as at risk for falls related to weakness, and Activities of Daily Living (ADL's) assistance related to weakness and decreased mobility. Further review of the CCP revealed the facility had also care planned Resident #1 for potential nutritional risk and wandering. Review of Resident #1's Progress Note, dated 07/12/2021, revealed Resident #1's seventy-two (72) hour meeting was held with the SSD, Therapy staff and the resident. Continued review revealed Resident #1 was informed he/she needed to continue to work with therapy to gain more independence and continence. Additionally, the Note documented Resident #1 wanted to return to the homeless shelter where he/she previously resided. Interview with the homeless shelter's Director of Programs, on 07/27/2021 at 1:40 PM, revealed the shelter did not provide assistance in any way with medications, including storage or dispensing of medications. Continued interview revealed clients at the homeless shelter had to leave the shelter every day at 7:00 AM and could check-in back in for the evening, starting at 4:00 PM. She stated if the clients left any medications behind when leaving, staff collected the medication which they placed in a locked box. Per interview, the collected medications in the locked box were taken to a local Pharmacy where they were destroyed. Further interview revealed the homeless shelter had no support staff to assist clients with transfers (i.e. to and from a wheelchair), showers, and incontinence care. Interview with the previous SSD, on 08/24/2021 at 9:18 AM, revealed during the morning meeting on 07/17/2021, the DON notified her Resident #1 was leaving AMA that day. The SSD stated she voiced safety concerns regarding Resident #1 needing to be more independent prior to being discharged , and was concerned there was no wheelchair available. Continued interview revealed she knew Resident #1 was able to transfer on his/her own to the toilet and was able to feed himself/herself. The previous SSD stated she was not aware Resident #1 was an insulin dependent Diabetic. Further interview revealed after Resident #1 was discharged AMA to the homeless shelter, she notified Adult Protective Services (APS) of the unsafe discharge. Interview with the Assistant Director of Nursing (ADON), on 05/28/2021 at 3:23 PM, revealed approximately a week prior to Resident #1 leaving AMA, the DON and SSD discussed finding other placement for Resident #1 at another facility which would be able to accommodate the resident's wandering behaviors. Interview with the facility's previous DON, on 08/25/2021 at 1:27 PM, revealed the SSD was notified Resident #1 wanted to leave the facility and she took over the discharge process from the SSD. Continued interview revealed the SSD was responsible for coordinating and facilitating discharge of residents, including ensuring the residents had everything they needed. She stated Resident #1 was given a list of his/her medications at the time of discharge; however, no actual medications were given to him/her to take with him/her. Additionally, she revealed he/she was not given any money to purchase any supplies he/she might need. ` Interview with the previous Executive Director (ED), on 08/26/2021 at 4:30 PM, revealed she had not been made aware Resident #1 was discharged AMA until after the resident had already left the facility. She stated the SSD and clinical team communicated such matters in the facility's morning meeting. Further interview revealed staff in the morning meeting discussed any changes with a resident's discharge plan and the SSD made any updates as needed. Interview with the current SSD, on 09/03/21 at 2:56 PM, revealed her responsibilities were to ensure when a resident was discharged the resident was provided with all the necessary things they needed to maintain their goals and ensure their safety after discharge. She stated if those things were not completed for a resident prior to discharge, something bad could potentially happen to the resident. Interview with the current ED, on 09/03/2021 at 3:23 PM, revealed the SSD and clinical team should always work closely together to ensure a safe discharge for a resident. She stated discharge planning occurred early on to ensure all members of the clinical team were on the same pages regarding goals for the resident to be discharged . The facility alleged it implemented the following actions to remove immediacy: 1. The Regional Vice President of Operations (RVPO) and Vice President of Clinical Services (VPCS) reeducated the facility's Interdisciplinary Team (IDT) which included the Executive Director (ED), Director of Nursing (DON), Social Services Director (SSD) Dietary Manager (DM), Maintenance Director, Therapy Director, Activity Director, Assistant Director of Nursing (ADON), Human Resources Director (HR), Scheduler, Minimum Data Set (MDS) Coordinator, Assistant Housekeeping Director, and Admission Director on 07/20/2021. The education included the Against Medical Advice (AMA) Policy, AMA form, and the policy on Change in a Resident's Condition/Status (CIC) which included discharge without proper medical authority, and care plan revisions to ensure a safe discharge with a posttest administered. 2. On 07/21/2021, the RVPO and VPCS completed an audit on all current residents to ensure their Guardian status paperwork was in the medical record. 3. On 07/21/2021, the RVPO and VPCS completed an audit of all discharges from 06/01/2021 through 07/21/2021, to ensure proper discharge notification based on guardianship status. 4. The ED, DON, and SSD were no longer employed at the facility effective 07/21/2021. 5. The RVPO completed education to the Liaisons related to ensuring the facility knew about a resident's guardianship status and proper paperwork was provided. 6. Newly hired management members such as the ED, DON and SSD received education regarding care plans and the facility's discharge process to include CIC, discharge without proper medical authority and care plan revision, with a posttest. 7. Beginning 07/21/2021, any new admissions were to be audited by the IDT for guardianship status and discharge care planning five (5) days week for six (6) months. 8. The ED and/or DON were to review the results of the audits daily. 9. The ED, DON, and/or SSD were to submit results of the audit findings weekly times (x) six (6) months to the facility's Quality Assurance Performance Improvement (QAPI) Committee which was the IDT until the issue was resolved. The State Survey Agency (SSA) validated the removal plan by: 1. Review of facility documentation revealed reeducation was provided to the IDT team with a posttest provided with a completion score of 100% to all IDT members. Interview with the IDT members, on 09/17/2021 10:09 AM, 10:15 AM and 10:35 AM, revealed they received education regarding the facility's AMA policy and the form along with discharge procedures for someone wanting to leave AMA. Interview revealed they had also been educated regarding the care plan updates to ensure a safe discharge. 2. Record review revealed on 07/21/2021, Resident #1's care plan had been updated to reflect his/her guardianship status. Interview with the MDS Coordinator on 09/17/2021 at 12:33 PM, revealed she had updated Resident #1's care plan to reflect his/her guardianship status. 3. Review of facility documentation revealed on 07/21/2021 the RVPO and VPCS completed an audit of all discharges from 06/01/2021 through 07/21/2021 to ensure proper notification based on guardianship status. Interview with the Regional Vice President of Operations (RVPO), on 09/17/2021 at 9:20 AM, revealed she completed the audits to ensure no one had been missed, and to ensure the facility had residents who had guardianships were reflected on the resident's medical record. Interview with the Vice President of Clinical Services (VPCS), on 09/17/2021 at 2:33 PM, revealed she assisted with the audits and reviewed any guardianship discharges to ensure proper notifications were made as required. 4. Interview with the previous ED, DON and SSD revealed they were no longer employed at the facility. 5. Review of facility documentation revealed the facility's liaisons were educated regarding ensuring the facility was made aware of residents' guardianship status and that the facility received the proper paperwork. Interview with the facility's Liaison #1, on 09/17/2021 at 9:30 AM, revealed she completed education regarding: if a resident was coming to the facility and had a Guardian she was to notify the facility of who the Guardian was, and they would contact the Guardian. She stated the education also included the facility reaching out to a resident's Guardian to ensure the correct paperwork was provided and signed. Interview with the facility's Liaison #2, on 09/17/2021 at 9:55 AM, revealed she had education provided regarding receiving the appropriate guardianship paperwork and ensuring the facility was aware. Interview with the facility's Liaison #3, on 09/17/2021 at 9:34 AM, revealed she was educated regarding if she received a referral for a new resident and it was noted they had a Guardian, paperwork must be requested and identify the Guardian contact. Further interview revealed Liaison #3 stated the liaisons let the facility know the Guardian information which included the SSD. Interview with the facility's Liaison #4, on 09/17/2021 at 9:37 AM, revealed she completed education regarding the process of ensuring guardianship paperwork was clarified and the guardianship status of a resident was relayed to the facility. 6. Review of facility documentation revealed newly hired management members, the ED, DON and SSD received education on care plans and the discharge process. Interview with the ED and DON, on 09/17/2021 at 2:06 PM, revealed education was completed on the day of hire with completion a posttest which was reviewed and any questions discussed. 7. Review of facility documentation revealed audits were completed starting 07/21/2021 on new admissions for guardianship status and discharge care planning. Interview with the IDT members, on 09/17/2021 at 10:09 AM, 10:15 AM and 10:35 AM, revealed new admissions were being reviewed in the facility's clinical meeting for guardianship status and discharge care plans. 8. Review of facility documentation regarding the audits performed revealed the ED had been reviewing the audit results daily. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she had been reviewing the audits daily. 9. Review of facility documentation revealed the ED or DON would report the audit results to QAPI weekly. Interview with the ED, on 09/17/2021 at 2:11 PM, revealed she had been reviewing the audits and discussing trends and improvements with the QAPI team members. Interview with the DON, on 09/17/2021 at 2:33 PM, revealed the QAPI meeting had been discussing trends and improvements based on the audit findings. Interview with the QAPI Committee members, on 09/17/2021 at 10:15 AM and 10:35 AM, revealed they reviewed the audit results and discussed improvements.

Based on interviews, record review, and review of the facility's policy it was determined the facility failed to immediately consult with the resident's physician; and, notify the resident's representative(s) when there was a significant change in the resident's physical condition (that is, a deterioration in health in either life-threatening conditions or clinical complications) for one (1) of twenty-one (21) sampled residents (Resident #20). The facility admitted Resident #20 on 09/23/2019. Closed record review revealed the resident's weight on 12/17/2020 was one-hundred and twenty-seven point six pounds (127.6 lb.) and one-hundred and nineteen point eight lbs. (119.8) on 01/12/2021. This reflected a six point eleven (6.11%) weight loss in less than one (1) month, which reflected a severe weight loss. However, there was no documented evidence the facility notified the medical provider or the Responsible Party (RP) of the severe weight loss. Resident #20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the Medication Administration Record (MAR) revealed from 12/01/2020 to 01/18/2021 the facility did not record the administration of Resident #20's [MEDICATION(S)] tablets (appetite stimulant) for several doses. There was no documented evidence the facility notified the medical provider or the resident's RP. The Registered Dietician recommended Resident #20 continue the Nutritional at Risk Program (NAR) and recommended weekly weights for three (3) months to monitor any significant changes. Review of the resident's weight log revealed the resident's weekly weighs were not obtained 10 weeks of the three-month period from 10/05/2020 through 01/05/2021. The facility failed to notify the medical provider and the responsible party (RP) of the resident's severe weight loss, missed treatments, missed weights, and the resident's poor intake. Resident #20 had abnormal laboratory test values; the resident's sodium level was abnormal. The provider ordered intravenous fluids (IVFs) and to repeat the lab work after the IV fluids had been administered. However, the facility did not administer the fluids, and did not repeat the labs. Interview with Resident #20's family member revealed she was appalled at how much weight the resident had lost while living at the facility and that the facility never informed her of the amount of weight the resident had lost. The facility failed to notify the medical provider and the responsible party (RP) of the resident's severe weight loss, missed treatments, missed weights, and the resident's poor intake. The facility transferred Resident #20 to the hospital on 01/18/2021. Resident #20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on 04/26/2021 and determined to exist on 09/30/2020. The facility's failure to have an effective system in place to ensure the medical providers and the RP received immediate notification of changes for all residents has caused or was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified at 42 CFR 483.25 Quality of Care (F692 at S/S of J), 42 CFR 483.10 Quality of Care (F580 at S/S of J), and 42 CFR 483.21 Quality of Care (F656 at S/S of J) and were determined to exist on 09/30/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/03/2021 alleging removal of the Immediate Jeopardy on 05/04/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/04/2021, prior to exit on 05/14/2021, with remaining non-compliance at a Scope and Severity of a D while the facility developed and implemented a Plan of Correction, and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated 05/2017, revealed the facility promptly notified the resident, his/her Attending Physician, and representative (sponsor) of changes in the resident's medical condition and/or status. Closed record review revealed the facility admitted Resident #20 on 09/23/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID 19 on 01/08/2021. Closed record review of the Quarterly Minimum Data Set (MDS), dated and signed on 01/08/2021, revealed Resident #20's Brief Interview Mental Status (BIMS) score as one (1). The facility determined the resident was not interviewable. Continued review of the MDS revealed the resident required limited assistance of one (1) person with eating, and the resident consumed a mechanically altered diet. Review of Resident #20's Comprehensive Care Plan, dated 09/30/2020, revealed the focus: Resident #20 had nutritional problem or potential nutritional problem of dehydration related to mechanically altered diet restrictions. The goal(s) included the resident will have gradual weight gain of two (2) to three (3) pounds per month times three (3) months; the resident will show no signs or symptoms of dehydration, and the resident will maintain good oral (PO) intakes of greater than or equal to fifty percent (50%) at most meals. The target date was 03/10/2021 and the interventions included: to monitor/record/report to Medical Physician signs and symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss (three (3) pounds in one (1) week, greater than five (5) % in one (1) month, greater than seven point five (7.5) % in three (3) months, or greater than ten (10) percent (%) in six (6) months, provide and serve supplements as ordered: nutrition shake three times a day (TID), and fortified foods, provide and serve diet as ordered, monitor intake and record every meal, and weigh as ordered. Closed record review of a Dietary Progress note, dated and signed on 09/30/2020 by the Registered Dietician (RD) #2 stated Resident #20's current body weight was one-hundred and thirty one point four pounds (131.4) (lbs.) on 09/03/2020, and noted a fifteen point four percent (15.4%) weight loss between 06/12/2020 and 07/14/2020, and weight had restored since. The progress note continued that the resident's weight trend showed a decline for four (4) months. Further notes revealed it would be beneficial for the resident to have a gradual weight gain of two (2) pounds to three (3) pounds (lbs.) per month. Continued review revealed the RD recommended nutrition shake three (3) times a day with meals, continue to monitor resident in NAR, recommend weekly weights for three (3) months to monitor for any significant changes. Continued review of the Order Summary Report revealed an order stating weekly weights times three (3) months every dayshift, every Monday, for three (3) months. The order was dated 10/01/2020 and started date 10/05/2020, and the end date was 01/05/2021. Review of the Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated 10/2020, 11/2020, 12/2020, and 01/2021 revealed the order for weekly weights times three (3) months every day shift and every Monday with a start date of 10/05/2020. Review of Resident #20's MAR/TAR, and the Weight Log revealed no documentation of the resident's weight for the weeks of 10/05/2020, 10/19/2020, 10/26/2020, 11/02/2020, 11/09/2020, 11/16/2020, 11/23/2020 or 11/30/2020, 12/28/2020, or 01/04/2021. Continued review of Resident #20's 01/2021 Weight Log revealed the resident was weighed on 01/12/2021 at one-hundred and nineteen point eight (119.8) lbs and in comparison to the resident's previous weight of one-hundred and twenty-seven point six (127.6) lbs. on 12/17/2020, this reflected a weight loss of six point eleven (6.11) percent (%) of his/her body weight in less than one (1) month which indicating a severe weight loss. However, there was no documented evidence the medical provider or RP were notified. Interview with Licensed Practical Nurse (LPN) #4, on 04/26/2021 at 1:00 PM, revealed she was Resident #20's nurse on 01/12/2021, however, she was not informed by staff of the resident's significant/severe weight loss or she would have immediately notified the physician. She revealed if significant/severe weight loss was not identified and addressed by staff then a resident could get dehydrated, weak, and malnourished and die. Interview with Licensed Practical Nurse #1, on 04/15/2021 at 10:20 AM, and 04/20/2021 at 12:19 PM, revealed she was a caregiver for Resident #20, but was no longer employed by the facility. She stated she could not recall the resident being flagged for weight loss in the Point Click Care (PCC) system or if the resident had a significant weight loss on 01/12/2021. She stated if Resident #20 had a weight lost, she would have notified someone in Management as well as the family, and she believed she did notify the family of the weight loss. She revealed anytime a resident had a significant/severe weight loss nursing should always do immediate interventions such as re-weigh the resident, and notify the medical provider and the family. She stated if Resident #20 sustained a significant/severe weight loss on 01/12/2021, she would have charted that immediately along with any interventions in the PCC system. Record of Resident #20's clinical record revealed staff had not identified a six point eleven (6.11) % weight loss in less than one month (12/17/2020 through 01/12/2021), or had reported the weight loss to the medical provider, the DON, the RD, or the family. Interview with the Director of Nursing, on 04/15/2021 at 10:51 AM, revealed she started working at the facility on 02/01/2021. She revealed when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Minimum Data Set (MDS) Nurse, on 04/15/2021 at 11:15 AM, revealed she was the Interim DON in the facility from 12/2020 until the new DON started on 02/2021. She stated she did not really remember Resident #20 and did not recall any staff person alerting her about a severe/significant weight change on 01/12/2021. She stated if she had known Resident #20 sustained a significant/severe weight loss, she would have alerted the physician, the family, the dietary manager, and the registered dietician immediately. Interview with LPN #3, on 04/15/2021 at 2:21 PM, revealed anytime a resident lost a significant/severe amount of weight, the doctor, the family, and the DON were to be notified about the change so other interventions could be put into place to help the resident gain weight. Interview with the Registered Dietician (RD), on 04/15/2021 at 11:47 AM, and 04/19/2021 at 11:43 AM, revealed she started working as the RD in the facility the first week of December, 2020 and her role was to monitor and ensure residents had a stable weight. She revealed Resident #20 was added to NAR on 01/14/2021 after he/she sustained a weight loss of 6.11% in thirty (30) days. She stated she was not made aware by the facility that Resident #20 experienced a severe weight loss on 01/12/2021. However, she became aware of the resident's weight loss after reviewing the Monthly Weight Report. She revealed she would have assessed the resident's weight loss sooner if the facility had made her aware of the weight loss when it occurred. The RD revealed she could have started the resident on new interventions such as a nutritional supplement and ordered labs. Review of Resident #20's Medication Administration Record/Treatment Administration Record (MAR/TAR), dated 12/2020, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the medication was not documented as administered to Resident #20 on 12/06/2020, 12/07/2020, 12/19/2020, 12/25/2020, or 12/29/2020. Continued review of the MAR/TAR dated 01/2021 revealed no documentation of the [MEDICATION(S)] on 01/02/2021, 01/08/2021or 01/16/2021. Interview with LPN #6, on 04/20/2021 at 12:10 PM, who was Resident #20's nurse in 12/2020. She revealed she did not remember Resident #20, and had no idea why she did not document the [MEDICATION(S)] as given to Resident #20. She stated as she administered medications to each resident, she would initial the MAR and if the resident had refused the medication, she would have made a note in his/her chart as refused, and notified the doctor. Interview with LPN #7, on 04/20/2021 at 12:30 PM, revealed she did not know why she did not administer Resident #20's [MEDICATION(S)]. The LPN stated, she gets so busy with the residents, and works a lot of different shifts. She revealed she would normally document a reason in the resident's chart regarding why the resident did not receive the medication. She stated [MEDICATION(S)] could help to increase a resident's appetite. Interview with Resident #20's Physician, on 04/19/2021 at 3:06 PM, and 04/26/2021 at 10:50 AM, revealed he was made aware of Resident #20's severe weight loss by a physician at a local Emergency Department (ED) on the day the resident was transferred from the facility (01/18/2021) to the ED with Hypoxemia. He stated he should have been made aware immediately that the resident had lost a severe amount of weight but he had not been made aware by the facility. He stated Resident #20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed he was not aware the resident had not continued to be monitored in the NAR program. He stated he had not been made aware of the missed [MEDICATION(S)] doses that had been ordered for the resident to increase his/her appetite, and he should have been made aware of the missed doses, with a reason why the resident did not receive the medication. Closed record review of Resident # 20's Amount Eaten and Fluids Document, dated 11/2020, revealed no documentation of the percentage of meals the resident had eaten on 11/02/2020 at 5:00 PM; 11/06/2020 at 9:00 AM, and 12:00 PM; 11/14/2020 at 5:00 PM; 11/18/2020 at 9:00 AM, and 12:00 PM; and, 11/19/2020 at 9:00 AM, 12:00 PM, and 5:00 PM. Continued closed record review of Resident #20's Amount Eaten and Fluids document, dated 12/2020, revealed no documentation of the percentage (%) of meals the resident had eaten on 12/01/2020 at 12:00 PM, and 5:00 PM, 12/03/2020 at 12:00 PM, and 5:00 PM, 12/04/2020 at 12:00 PM, and 5:00 PM, 12/05/2020 at 12:00 PM, and 5:00 PM, 12/06/2020 at 5:00 PM, 12/07/2020 at 12:00 PM, and 5:00 PM, 12/08/2020 at 9:00 AM, 12:00 PM, and 5:00 PM, 12/09/2020 at 12:00 PM, and 5:00 PM, 12/11/2020 at 12:00 PM, and 5:00 PM, 12/12/2020 at 5:00 PM, 12/15/2020 at 12:00 PM, and 5:00 PM. The resident refused the breakfast meal on 12/15/2020. Continued review of the Amount Eaten and Fluids Sheet revealed the resident refused oral fluids on 12/08/2020 other than his/her nutritional shakes. Record review of Resident #20's Intake Monitoring for 01/2021 revealed no documentation of the percentage (%) of meals the resident had eaten on 01/04/2021 at 5:00 PM, 01/05/2021 no meal intake was documented, 01/07/2021 at 12:00 PM, and 5:00 PM, 01/08/2021 at 5:00 PM, 1/11/2021 no meal intake had been documented , 01/13/2021 no meal intake was documented, and 01/15/2021 no meal intake was documented. The resident refused meals on 01/09/2021 at 9:00 AM, and 12:00 PM, and the resident refused all meals on 01/17/2021. Continued review of the Amount Eaten and Fluids Log revealed Resident #20 did not consume any fluids on 01/05/2021, 01/11/2021, 01/13/2021, and 01/15/2021 with the exception of the intake of a Nutrition Shake three times a day. However, the resident refused the Nutrition Shake on 01/13/2021and 01/15/2021. Record review revealed no documented evidence the medical provider and RP were notified. Interview with Resident #20's nurse, LPN #4, on 04/20/2021 at 11:12 AM, revealed when a resident would not eat or drink, it was the nurse's responsibility to go to the resident and offer encouragement and/or an alternate meal replacement. She stated the physician should have been notified when the resident missed several meals in a row. Interview with LPN #2, on 04/21/2021 at 2:00 PM, revealed anytime a resident did not eat two (2) meals in a row, the doctor and the family should be notified by the staff. She stated it was important for staff to document how much a resident consumed at each meal because it was important to monitor for refusals because the resident could lose weight. Interview with Unit Manager #1, on 04/21/2021 at 2:16 PM, revealed when Resident #20 refused meals and fluids, staff should have tried to figure out why he/she was not eating. She revealed when a resident did not eat or drink for three (3) meals, the physician and the family should be notified, if not sooner, and that other interventions could be put in place in order to prevent the resident from losing more weight. Interview with the Registered Dietician, on 04/15/2021 at 11:47 AM, and, 04/19/2021 at 2:00 PM, revealed she had not assessed Resident #20 in person due to Covid19 restrictions therefore the NAR meetings were held via teleconference. She revealed her role, as the RD, was to ensure residents maintained a stable weight. She became aware of Resident #20's severe weight loss by review of the Weight Change Report on 01/14/2021. She revealed that if staff had notified her sooner that the resident had a severe weight loss, she could have added additional supplements, and other treats such as ice cream and milk. She revealed by her review of Resident #20's percentage of diet and fluids consumed information, it appeared the resident had not eaten all three (3) meals, or any meals on 12/01/2020, 12/03/2020, 12/04/2020, 12/05/2020, 12/06/2020, 12/07/2020, 12/08/2020, 12/9/2020, 12/11/2020, 12/18/2020, 12/19/2020, 12/20/2020, 12/29/2020, 12/31/2020, 01/05/2021, 01/11/2020, 01/13/2020, and on 01/15/2020. Interview with Resident #20's Physician, on 04/19/2021 at 3:06 PM, revealed a decrease in Resident #20's oral intake, and his/her refusal of meals was primarily the reason why Resident #20 had suffered a severe/weight loss. He stated he thought the resident was on the NAR program, and was being weighed weekly because of his/her history of weight loss. He stated staff had not made him aware of the resident's decrease of, or refusal of, sufficient oral intake. The physician revealed that if staff had made him aware of the resident's severe weight loss, and refusal of meals, other interventions could have been put in place, such as a gastrostomy tube placement for enteral tube feedings, or the resident might have been placed in Palliative Care, and been kept comfortable. Record review of the Progress Note, signed and dated by the ARNP, on 01/15/2021at 7:43 AM, stated, .review of labs for (Resident #1) showed acute [CONDITION(S)] most likely related to poor fluid intake. Assessment and Plan- [CONDITION(S)] (A condition where sodium levels in the blood are abnormally high): Normal Saline (NS) at seventy-five (75) milliliters (ML), encourage fluids by mouth (PO), and recheck Basic Metabolic Panel (BMP) after the intravenous fluids (IV) have infused. Orders for this visit, NS at seventy-five (75) ML per hour times (x) one liter (due to [CONDITION(S)] and volume depletion), encourage PO fluids, and re-check a BMP after the IV fluids have infused. Review of the resident's MAR, dated 01/2021, revealed no documented evidence of the order for the IV fluids as ordered by the ARNP on 01/15/2021. Continued review of Resident #20's clinical record revealed no documented evidence staff had administered the IV fluids to Resident #20, nor had a follow-up BMP lab drawn after the IV infusion. In addition, there was no documented evidence the medical provider and RP were notified. Interview with the Administrator and the DON, on 04/16/2021 at 10:25 AM, revealed the order for Resident #20's IV fluids had not been entered onto the MAR/TAR nor were the IV fluids administered to the resident as ordered by the ARNP. Continued interview revealed they had not been made aware until this survey that the IV fluids with a repeat BMP had not been completed as ordered the resident. Interview with the ARNP, on 04/16/2021 at 11:00 AM, and 04/21/2021 at 12:23 PM, revealed he did not know the IV fluids or the repeat BMP lab had not been completed by the facility per his orders. Interview with the DON on, 04/22/2021 at 9:21 AM, revealed typically if a resident refused meals, and refused alternate meals, the staff should report this to the physician. She revealed Resident #20 had been placed on various interventions related to his/her history of weight loss to include nutritional supplements, medication, IV fluids, and follow-up labs. However, the DON stated the interventions had not been followed as ordered. She also stated anytime a resident had a significant/severe weight change, staff should notify the medical provider and the RP, and complete a Change in Condition Form in PCC, and that would trigger her to review the resident's progress notes. She was unable to provide documented evidence Resident #20's severe weight loss had been documented as a Change of Condition on 01/12/2021. Interview with the Administrator, on 04/22/2021 at 9:45 AM, revealed Resident #20 did have a history of weight loss. She stated her expectation from staff was that the percentage of meals and fluids consumed be documented in the resident's clinical record. She revealed anytime a resident had lost a significant or severe amount of weight, or refused several meals, the nurse should immediately notify the physician because the physician might want to consider other interventions such as evaluation of the resident for a tube feeding to prevent further weight loss. Review of the Progress Note/Change of Condition signed and dated by LPN #4 at 01/18/2021 at 1:05 PM revealed: Change in Condition, Signs and Symptoms: Hypoxemia, knees/nail beds/toes appear to be mottled, not eating for a few days, respirations thirty-six (36). ARNP notified at approximately 12:30 PM on 01/18/2021, tried to apply oxygen nasal cannula by different staff three (3) times but the resident kept taking the oxygen off. Per APRN order, the resident was sent to a local acute care hospital. Review of the hospital records revealed Resident #20 had been admitted to the Emergency Department (ED) on 01/18/2021 at 1:41 PM. Resident #20's sodium (NA) level was elevated at one-hundred and seventy-two (172), and the resident was given an intravenous (IV) fluid bolus. The hospital medical provider, upon physical exam in the ED, described the resident as cachectic and ill appearing. Resident #20's weight measured one-hundred (100) pounds (#). Resident #20 was admitted to the hospital from the ED with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Discharge Summary, dated 01/21/2021, and signed by the admitting, and discharge physician stated- Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Course-Resident #20 was admitted with Acute Kidney Injury (AKI), high sodium level, and dehydration. Resident was treated aggressively with IV fluids, and family chose to take the resident home with Hospice. Interview with the physician, on 04/19/2021 at 3:06 PM, and 04/26/2021 at 10:50 AM, revealed the facility had not made him aware Resident #20 had not received the ordered IV fluids and a repeat BMP lab until after the resident had been transferred to the hospital. He stated the IV fluids would have helped the resident with hydration at that time. He revealed Resident #20 should have been evaluated for a tube feeding for nutrition and fluid intake, so the medical team did not have to rely on his/her poor oral intake to maintain his/her weight. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #20 was discharged from the facility on 01/18/2021, and did not return. 2. Between 04/30/2021 and 05/03/2021, the DON, RD, ADON, MDS Nurse, and Nurse Managers reviewed the care plans for current residents who triggered for a significant weight loss based off their most recent monthly or weekly weight to ensure implementation of the interventions related to nutrition and weight monitoring. 3. The facility employees a total of ninety-two (92) staff, which includes contracted therapy, and housekeeping staff. As of 04/30/2021, seventy-two (72) were educated on policies related to notification to the provider and responsible party for situations such as, but not limited to, significant weight loss, missed doses of medications and supplements and poor intake, documentation of meal intake, comprehensive care plan process, significant weight loss, nutrition and hydration. The education was followed by a posttest to ensure understanding of the information. The education was conducted by the DON, ADON, Nurse Managers, Administrator, Activity Director, SDC, Social Services, after they were educated by the Regional Vice President of Clinical Services in a Train the Trainer session. The facility does employ agency staff, who were included in the training and post testing. After the alleged date of the removal of immediacy, no staff will be allowed to work without having received the education, and completing the posttest. A score of 100% will be required on the post test. If anyone does not achieve a 100% on the first attempt, additional education will be provided and a re-test will occur, until 100% is achieved. The education and posttest will be completed with all new staff during their orientation, prior to providing resident care. 4. On 04/30/2021, an ad hoc meeting was held with the QAPI. The committee consists of the DON, ADON, MDS Nurse, Nurse Managers, Administrator, Activity Director, SDC, SS, and the Medical Director. During this ad hoc meeting, the QAPI Committee reviewed the information in the IJ Template, audit plan, policies and processes related to change of condition, significant weight loss, missed doses of medication, or supplements, and poor intake, documentation of meal intake, comprehensive care plan process, significant weight loss, nutrition and hydration the education and the post test. No changes to the policies or the corrective plan to remove the immediacy. 5. The DON, ADON, Nurse Managers will review administration records for current resident who triggered for a significant weight loss based off their most recent, monthly or weekly weight who are care planned to receive nutritional supplement for compliance with implementation. 6. The DON, ADON, Nurse Managers, and Dining Services Manager will review meal consumption records for current residents who triggered for a significant weight loss based off their most recent monthly or weekly weight for implementation of interventions related to monitoring and documentation of meal intake. 7. The DON, ADON, Nurse Managers, and Dining Services Manager will review the MAR for current residents who triggered for a significant weight loss based off their most recent or weekly weights to ensure implementation of interventions related to medications being administered as ordered 8. The DON, ADON, Nurse Managers, and Dining Services Manager will review weekly, unless the NAR Committee deems a lower review schedule is appropriate for that resident, the Care Plan for the current residents who triggered for a significant weight loss based off their most recent or weekly weight in the NAR meeting for compliance with implementation for interventions related to provider notification of the weight loss. 9. The DON, ADON, Nurse Managers, and Dining Services Manager will review the MAR for current residents who triggered for a significant weight loss based off their most recent or weekly weights for compliance with implementation for interventions related to labs 10. These audits will begin on 05/03/2021 and will be conducted daily (with the exception of the NAR meeting review until removal of immediacy is achieved, then decrease to three times a week, then decrease to weekly for one month, then decrease to monthly for two months. 11. The results of the audits will be reviewed by QAPI, which consists of the Administrator, DON, ADON, SDC, Therapy Manager, Nurse Managers, Dietary Services, Plant Operations, Admission, Activity Staff, Human Resource Coordinator, and the Medical Director, which will meet weekly, until removal of immediacy is achieved. The QAPI will make recommendations and will determine ongoing compliance and make changes to the action plan and audit schedule if deemed appropriate. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #20 was discharged to a local ED on 01/18/2021, and did not return to the facility. 2. Record review revealed the facility had identified fifteen residents who triggered for a significant weight loss to ensure implementation of the interventions related to nutrition and weight monitoring. Monitoring of meals measured and noted, and the physician was notified for residents who failed to consume 50% of their meals for three consecutive days. Review of the resident's plan of care revealed interventions are in place for each individual resident identified to have a significant weight loss. Interview with the MDS Nurse, on 05/13/2021 at 2:10 PM, revealed she and the dietician reviewed and updated the care plans for fifteen residents identified to have significant weight loss. Interview with a Unit Manager#1, on 05/13/2021 at 2:30 PM, revealed the Interdisciplinary Team was also involved with the NAR committee, and residents care plans are reviewed, and updated as needed. She revealed the nurses could do updates to the care plans immediately. Interview with the DON, on 05/14/2021 at 10:00 AM, revealed the review of the fifteen residents who triggered for weight loss had their care plans updated for appropriate interventions, but some of the care plans stayed the same. 3. Record review revealed a signed roster dated 04/30/2021 titled, Staff Development Program Plan, topic - Train the Trainer was presented to the facility Department Heads (ADON, Admissions, Unit Manager, Maintenance, DON, Human Resource Specialist, SDC, Dietary Manager and the Director of Rehabilitation by the Vice President of Clinical Services. The program objectives included policies on Significant Weight Loss (revised on 04/2021), Hydration - Clinical Protocol, Resident Hydration and Prevention of Dehydration, Hydration CMS Critical Pathway, and Comprehensive Care Plan. Further review revealed a 100% completed employee training roster, dated 04/30/2021, 05/01/2021 of facility staff who had completed the training, and the posttest with one-hundred percent (100%) passing score. Posttest content tested staff knowledge of notification of changes, monitoring nutritional status, ensuring implementation of the plan of care, weight loss/notifications, medication refusals, following medication orders, intravenous fluids, documentation of medication administration and meal intakes, comprehensive care plan, implementation of the comprehensive care plan, NAR committee, weekly and monthly weights. Interview with Licensed Practical Nurse #2, on 05/14/2021 at 12:05 PM, revealed she completed recent trainin [TRUNCATED]

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure the individualized care plan was implemented for one (1) of twenty-one (21) sampled residents (Resident #20). Resident #20 was care planned as a nutritional risk: however, the facility failed to follow the care plan, and the resident experienced a severe weight loss. The facility admitted Resident #20 on 09/23/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Comprehensive Care Plan, dated 09/30/2020 revealed the focus stated the resident had a nutritional problem or potential nutritional problem of dehydration related to mechanically altered diet restrictions. The goal was the resident will have gradual weight gain of two (2) to three (3) pounds per month times three (3) months; the resident will show no signs or symptoms of dehydration; and the resident will maintain good oral (PO) intakes of greater than or equal to fifty (50) percent (%) at most meals. The interventions included to monitor/record/report to Medical Physician signs and symptoms of malnutrition: significant weight loss: provide and serve diet as ordered, monitor intake and record every meal, and weigh as ordered. Record review revealed from 12/01/2020 to 01/18/2021, the facility did not record the resident's intake for multiple meals as ordered and care planned. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 had abnormal lab value; the sodium was high. The Advance Registered Nurse Practititinor order intravenous fluids and to repeat the lab. Record review and interview with staff revealed the facility failed to administer intravenous fluids, and repeat labs as ordered by a medical provider. However, the facility failed to revise the resident's care plan to include the new orders. Record review revealed on 09/30/2020, the Registered Dietician ordered for Resident #20 to continue with Nutritional at Risk Program (NAR) and recommended weekly weights for three (3) months to monitor any significant changes. Review of the resident's weight log revealed the facility did not document the resident's weight for 10 weeks of the three- month period. The resident's weight on 12/17/2020 was one-hundred and twenty-seven point six pounds (127.6 lbs.) and one-hundred and nineteen point eight pounds (119.8 lb.) on 01/12/2021. This reflected a six point eleven percent (6.11%) weight loss in less than one (1) month, which reflected a severe weight loss. The facility transferred Resident #20 to the hospital on 01/18/2021. Resident #20 was admitted to the hospital from the ED with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Discharge Summary, dated 01/21/2021, and signed by the admitting, and discharge physician included the Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #20 returned home from the hospital with Hospice Care, and passed away on 01/30/2021. Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on 04/26/2021 and were determined to exist on 09/30/2021. The facility's failure to have an effective system in place to ensure facility staff implemented resident care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.25 Quality of Care (F692 at S/S of J), 42 CFR 483.10 Quality of Care (F580 at S/S of J, and 42 CFR 483.21 Quality of Care (F656 at S/S of J) were determined to exist on 09/30/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/03/2021 alleging removal of the Immediate Jeopardy on 05/04/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/04/2021, prior to exit on 05/14/2021, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 01/13/2018, stated the purpose of the policy was to ensure the provision of services to enable residents to live with dignity, and support the resident's goals, choices, and preferences including goals related to their daily routines. The Comprehensive Care Plan described the services to be furnished to attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Care Planning/Interdisciplinary Team was responsible for the review and updating of the care plans when there was a significant change in the resident's condition or when the desired outcome was not met. The facility admitted Resident #20 on 09/23/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with Covid 19 on 01/08/2021. Closed record review of the Quarterly Minimum Data Set (MDS), dated and signed on 01/08/2021, revealed the facility assessed Resident #20's Brief Interview Mental Status (BIMS) score as one (1) and determined the resident was not interviewable. Continued review of the MDS revealed the resident required limited assistance of one (1) person with eating, and the resident consumed a mechanically altered diet. Closed record review of a Dietary Progress note, dated and signed on 09/30/2020 Registered Dietician (RD) #2 revealed Resident #20's current body weight was one-hundred and thirty one point four pounds (131.4) (lbs.) on 09/03/2020. Further review revealed this weight noted a fifteen point four percent (15.4%) weight loss between 06/12/2020 and 07/14/2020, and weight had restored since. The Note stated the weight trend showed a decline for four months. It would be beneficial to the resident to have a gradual weight gain of two (2) pounds to three (3) pounds (lbs.) per month. The RD recommended nutrition shake three times a day with meals, continue to monitor resident in NAR, recommend weekly weights for three months to monitor for any significant changes. Review of Resident #20's care plan, dated 09/30/2020, did not reveal the resident to be on the Nutritionally at Risk (NAR) program. However, continued review of the resident's care plan revealed the intervention to provide and serve supplements as ordered. Review of Resident #20's MAR/TAR dated 12/2020 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the medication was not administered to Resident #20 on 12/06/2020, 12/07/2020, 12/19/2020, 12/25/2020, or 12/29/2020. Continued review of the MAR/TAR dated 01/2021, revealed no documented evidence the facility administered the resident's [MEDICATION(S)] on 01/02/2021, 01/08/2021 or 01/16/2021, as directed per the care plan. Review of the care plan, dated 09/30/2020, revealed the intervention to weigh the resident as ordered. Review of the Order Summary Report revealed an order, which stated weekly weights times three (3) months every dayshift, every Monday, for three (3) months. The order was dated 10/01/2020 with a start date of 10/05/2020, and an end date 01/05/2021. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's 10/2020 MAR/TAR, and the Weight Log revealed no documentation of the resident's weight on 10/05/2020, 10/19/2020, or 10/26/2020. Review of Resident #20's 11/2020 MAR/TAR, and the Weight Log revealed no documentation of the resident's weight on 11/02/2020, 11/09/2020, 11/16/2020, 11/23/2020 or 11/30/2020. Review of Resident #20's 12/2020 MAR/TAR and the Weight Log, dated 12/2020, and revealed no documentation of the resident's weight on 12/28/2020. Review of Resident #20's 01/2021 MAR/TAR and Weight Log, dated 01/2021 revealed no documentation of the resident's weight on 01/04/2021, nor monitoring as described in the plan of care. Review of the resident's care plan revealed the interventions to monitor, record and report to the physician signs and symptoms as needed for significant weight loss, greater than five percent (5%) in one month. Review of Resident #20's 01/2021 Weight Log revealed the facility obtained the resident's weight on 01/12/2021. The resident weighed one-hundred and nineteen point eight pounds (119.8 lbs.). Continued review revealed that in comparison to the resident's previous weight of one-hundred and twenty-seven point six (127.6 lbs.) on 12/17/2020, the resident had lost 6.11% of his/her body weight in less than one month which reflected a severe weight loss. Closed record review revealed the facility did not follow the resident's individualized care plan related to alteration of nutrition. The facility failed to notify the physician of the resident's significant/severe weight loss as directed, per the plan of care. Review of Resident #20's care plan interventions, dated 09/30/2020, revealed- Intervention, monitor intake, and record every meal. Closed record review of Resident # 20's Amount Eaten and Fluids Document, dated 11/2020, revealed no documentation of the percentage of meals the resident had eaten on 11/02/2020 at 5:00 PM; 11/06/2020 at 9:00 AM, and 12:00 PM; 11/14/2020 at 5:00 PM; 11/18/2020 at 9:00 AM, and 12:00 PM; and, on 11/19/2020 at 9:00 AM, 12:00 PM, and 5:00 PM. Continued review of Resident #20's Amount Eaten and Fluids document, dated 12/2020, revealed no documentation of the percentage (%) of meals the resident had eaten on 12/01/2020 at 12:00 PM, and 5:00 PM; 12/03/2020 at 12:00 PM, and 5:00 PM; 12/4/2020 at 12:00 PM, and 5:00 PM;12/05/2020 at 12:00 PM, and 5:00 PM;12/06/2020 at 5:00 PM;12/07/2020 at 12:00 PM, and 5:00 PM;12/08/2020 at 9:00 AM, 12:00 PM, and 5:00 PM;12/09/2020 at 12:00 PM, and 5:00 PM; 12/11/2020 at 12:00 PM, and 5:00 PM; 2/12/2020 at 5:00 PM; and, on 12/15/2020 at 12:00 PM, and 5:00 PM. The resident refused the breakfast meal on 12/15/2020. Continued review of the Amount Eaten and Fluids Sheet revealed the resident refused oral fluids on 12/08/2020 other than his/her nutritional shakes. Record review of Resident #20's Intake Monitoring for 01/2021 revealed no documentation of the percentage (%) of meals the resident had eaten on 01/04/2021 at 5:00 PM, 01/05/2021 no meal intake had been documented, 01/07/2021 at 12:00 PM, and 5:00 PM, 01/08/2021 at 5:00 PM, 1/11/2021 no meal intake had been documented, 01/13/2021 no meal intake had been documented, and 01/15/2021 no meal intake had been documented. The resident refused meals on 01/09/2021 at 9:00 AM, and 12:00 PM, and the resident refused all meals on 01/17/2021. Continued review of the Amount Eaten and Fluids Log revealed Resident #20 did not consume any fluids on 01/05/2021, 01/11/2021, 01/13/2021, and 01/15/2021 with the exception of the intake of a Nutrition Shake three times a day. However, the resident refused the Nutrition Shake on 01/13/2021 and 01/15/202. Record review revealed no documented evidence the facility notified the medical provider of the resident's meal intake percentage, as per the care plan. Review of the Progress Note, signed and dated by the ARNP on 01/15/2021 at 7:43 AM revealed Resident #1's lab results showed acute [CONDITION(S)] most likely related to poor fluid intake. Assessment and Plan- [CONDITION(S)] (A condition where sodium levels in the blood are abnormally high). Continued review revealed orders for normal saline NS at seventy-five (75) ml per hour, times (x) one liter (due to [CONDITION(S)] and volume depletion), encourage PO fluids, and re-check a BMP after the IV fluids have infused. However, the facility failed to revise the care plan to include the new order. Interview with Licensed Practical Nurse (LPN) #1, on 04/15/2021 at 10:20 AM, revealed the purpose of a care plan was to identify a diagnosis, develop goals for each resident, and maintain a baseline that was good for the resident. She revealed care plan revisions should be made when there was a change in the resident and nursing could always initiate immediate interventions if necessary. LPN #1 stated she was not sure if Resident #20's care plan had been changed or not. She revealed if a plan of care was not followed, harm to a resident could occur. Interview revealed she could not honestly remember if she had referred to Resident #20's care plan when the resident was weighed on 01/12/2021, or if the resident had a weight change. Interview with the Minimum Data Set (MDS) Nurse, on 04/15/2021 at 11:15 AM, and, 04/26/2021 at 11:42 AM, revealed the purpose of a care plan was to guide a resident's care and the plan of care for each resident was updated with the Quarterly Assessments, and updated whenever needed. She stated she really did not remember Resident #20, and could not recall if staff had informed her of the resident's weight loss. She stated if she had been given information from staff that the resident had lost a significant amount of weight, she would have notified the physician, the Responsible Party (RP), the Registered Dietician (RD) and the Dietary Manager. The MDS Nurse stated the resident's care plan would also be updated with any new interventions provided by the physician or dietician. She stated if the care plan was not followed, the outcome for a resident could be a delay in care, a decline in health as well as slow their progress. Interview with RD #1, on 04/20/2021 at 09:41 AM, revealed it was important for her to know what percentage (%) of meals a resident consumed in order to analyze any pending changes in weight loss. She stated staff should follow the plan of care when a resident, such as Resident #20, was at risk for weight loss. Interview with Registered Nurse #1, on 04/19/2021 at 12:31 PM, revealed the purpose of a care plan was for any staff who provided care to a resident to be aware and focused on the specific needs of each resident. The RN revealed the nurses could update the care plan anytime an update was needed. She stated if a resident had been placed on NAR, she would expect to see that incorporated in the plan of care because that meant the resident might have weight issues. Interview with Unit Manager #1, on 04/19/2021 at 1:00 PM, revealed the purpose of a care plan was to direct staff on how to care for the residents. She stated that it guided everything we do for our residents. Continued interview revealed the facility met daily in the mornings to discuss any updates with residents' care plans. She revealed it was important for staff to use the care plan and update it as needed so staff would know what was going on with each resident. Interview with Licensed Practical Nurse (LPN) #5, on 04/19/2021 at 2:13 PM, revealed the purpose of a plan of care was to provide staff information on what each resident's required needs, and to keep the resident safe. She revealed a resident's care plan should be followed, and kept up to date by the nurses. She stated it was important for staff to follow the care plan because one mistake could be bad for the resident. Interview with the Director of Nurses (DON) on 04/22/2021 at 9:21 AM, revealed the facility reviewed new medical provider orders every day, and assessed for any updates that needed to be made on the individualized care plan during daily clinical meetings. The DON stated it was important for staff to be familiar with each resident's care plan because the care plan was the only way staff knew how to take care of the residents. She stated Resident #20's care plan should have been reviewed, updates made, and followed. Continued review revealed the outcome for a resident, if the care plan was not followed, was highly dependent on what the specific care plan was about. She stated for Resident #20, the care plan should have been reviewed and revised for accuracy. Interview with the Administrator, on 04/22/2021 at 9:45 AM, revealed that when a resident had a change in condition, it was important for the nurse to enter this information into Point Click Care (PCC). She revealed Resident #20 had not had a change in condition completed by the nurse on 01/18/2021 when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the plan of care was the center of communication of each resident's care, and should be followed by staff. She stated if the plan of care was not followed, the outcome to the resident would vary case by case. Review of the hospital records revealed Resident #20 had been admitted to the ED(Emergency Department) on 01/18/2021 at 1:41 PM. Resident #20's sodium (NA) level was elevated at one-hundred and seventy-two (172), and the resident was given an intravenous (IV) fluid bolus. The hospital medical provider, upon physical exam in the ED, described the resident as cachectic and ill appearing. Resident #20's weight measured one-hundred (100) pounds (#). Resident #20 was admitted to the hospital from the ED with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Discharge Summary, dated 01/21/2021, and signed by the admitting, and discharge physician stated- Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge Condition- Hospice. Hospital Course-Resident #20 was admitted with Acute Kidney Injury (AKI), high sodium level, and dehydration. Resident was treated aggressively with IV fluids, and family chose to take the resident home with Hospice. Interview with Resident #20's physician, on 04/19/2021 at 3:06 PM, revealed a decrease in Resident #20's oral intake, and his/her refusal of meals was the primary reason why Resident #20 had suffered a severe/weight loss. He stated he thought the resident was on the NAR program, and was being weighed weekly because of his/her history of weight loss. He revealed staff had not made him aware of the resident's decrease of, or refusal of, sufficient oral intake. The physician revealed had staff made him aware of the resident's severe weight loss, and refusal of meals, other interventions could have been put in place, such as a gastrostomy tube placement for enteral tube feedings, or the resident might have been placed in Palliative Care, and been kept comfortable. He also revealed if the facility had followed the resident's care plan, then the resident might not have been harm. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #20 was discharged from the facility on 01/18/2021, and did not return. 2. Between 04/30/2021 and 05/03/2021, the DON, RD, ADON, MDS Nurse, and Nurse Managers reviewed the care plans for current residents who triggered for a significant weight loss based off their most recent monthly or weekly weight to ensure implementation of the interventions related to nutrition and weight monitoring. 3. The facility employees a total of ninety-two (92) staff, which includes contracted therapy, and housekeeping staff. As of 04/30/2021, seventy-two (72) were educated on policies related to notification to the provider and responsible party for situations such as, but not limited to, significant weight loss, missed doses of medications and supplements and poor intake, documentation of meal intake, comprehensive care plan process, significant weight loss, nutrition and hydration. The education was followed by a posttest to ensure understanding of the information. The education was conducted by the DON, ADON, Nurse Managers, Administrator, Activity Director, SDC, Social Services, after they were educated by the Regional Vice President of Clinical Services in a Train the Trainer session. The facility does employ agency staff, who were included in the training and post testing. After the alleged date of the removal of immediacy, no staff will be allowed to work without having received the education, and completing the posttest. A score of 100% will be required on the post test. If anyone does not achieve a 100% on the first attempt, additional education will be provided and a re-test will occur, until 100% is achieved. The education and posttest will be completed with all new staff during their orientation, prior to providing resident care. 4. On 04/30/2021, an ad hoc meeting was held with the QAPI. The committee consists of the DON, ADON, MDS Nurse, Nurse Managers, Administrator, Activity Director, SDC, SS, and the Medical Director. During this ad hoc meeting, the QAPI Committee reviewed the information in the IJ Template, audit plan, policies and processes related to change of condition, significant weight loss, missed doses of medication, or supplements, and poor intake, documentation of meal intake, comprehensive care plan process, significant weight loss, nutrition and hydration the education and the post test. No changes to the policies or the corrective plan to remove the immediacy. 5. The DON, ADON, Nurse Managers will review administration records for current resident who triggered for a significant weight loss based off their most recent, monthly or weekly weight who are care planned to receive nutritional supplement for compliance with implementation. 6. The DON, ADON, Nurse Managers, and Dining Services Manager will review meal consumption records for current residents who triggered for a significant weight loss based off their most recent monthly or weekly weight for implementation of interventions related to monitoring and documentation of meal intake. 7. The DON, ADON, Nurse Managers, and Dining Services Manager will review the MAR for current residents who triggered for a significant weight loss based off their most recent or weekly weights to ensure implementation of interventions related to medications being administered as ordered 8. The DON, ADON, Nurse Managers, and Dining Services Manager will review weekly, unless the NAR Committee deems a lower review schedule is appropriate for that resident, the Care Plan for the current residents who triggered for a significant weight loss based off their most recent or weekly weight in the NAR meeting for compliance with implementation for interventions related to provider notification of the weight loss. 9. The DON, ADON, Nurse Managers, and Dining Services Manager will review the MAR for current residents who triggered for a significant weight loss based off their most recent or weekly weights for compliance with implementation for interventions related to labs 10. These audits will begin on 05/03/2021 and will be conducted daily (with the exception of the NAR meeting review until removal of immediacy is achieved, then decrease to three times a week, then decrease to weekly for one month, then decrease to monthly for two months. 11. The results of the audits will be reviewed by QAPI, which consists of the Administrator, DON, ADON, SDC, Therapy Manager, Nurse Managers, Dietary Services, Plant Operations, Admission, Activity Staff, Human Resource Coordinator, and the Medical Director, which will meet weekly, until removal of immediacy is achieved. The QAPI will make recommendations and will determine ongoing compliance and make changes to the action plan and audit schedule if deemed appropriate. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #20 was discharged to a local ED on 01/18/2021, and did not return to the facility. 2. Record review revealed the facility had identified fifteen residents who triggered for a significant weight loss to ensure implementation of the interventions related to nutrition and weight monitoring. Monitoring of meals measured and noted, and the physician was notified for residents who failed to consume 50% of their meals for three consecutive days. Review of the resident's plan of care revealed interventions are in place for each individual resident identified to have a significant weight loss. Interview with the MDS Nurse, on 05/13/2021 at 2:10 PM, revealed she and the dietician reviewed and updated the care plans for fifteen residents identified to have significant weight loss. Interview with a Unit Manager#1, on 05/13/2021 at 2:30 PM, revealed the Interdisciplinary Team was also involved with the NAR committee, and residents care plans are reviewed, and updated as needed. She revealed the nurses could do updates to the care plans immediately. Interview with the DON, on 05/14/2021 at 10:00 AM, revealed the review of the fifteen residents who triggered for weight loss had their care plans updated for appropriate interventions, but some of the care plans stayed the same. 3. Record review revealed a signed roster dated 04/30/2021 titled, Staff Development Program Plan, topic - Train the Trainer was presented to the facility Department Heads (ADON, Admissions, Unit Manager, Maintenance, DON, Human Resource Specialist, SDC, Dietary Manager and the Director of Rehabilitation by the Vice President of Clinical Services. The program objectives included policies on Significant Weight Loss (revised on 04/2021), Hydration - Clinical Protocol, Resident Hydration and Prevention of Dehydration, Hydration CMS Critical Pathway, and Comprehensive Care Plan. Further review revealed a 100% completed employee training roster, dated 04/30/2021, 05/01/2021 of facility staff who had completed the training, and the posttest with one-hundred percent (100%) passing score. Posttest content tested staff knowledge of notification of changes, monitoring nutritional status, ensuring implementation of the plan of care, weight loss/notifications, medication refusals, following medication orders, intravenous fluids, documentation of medication administration and meal intakes, comprehensive care plan, implementation of the comprehensive care plan, NAR committee, weekly and monthly weights. Interview with Licensed Practical Nurse #2, on 05/14/2021 at 12:05 PM, revealed she completed recent training at the facility. She stated some of the training focused on recording, and reporting weights, resident refusal of meal (s), notification of the medical providers and the Responsible Party with any changes in a resident, obtaining resident weights in a timely manner, and reporting any discrepancies in a resident's weight in a timely manner, and staff should always document a residents intake and output. On 05/13/2021,interview with the Dietary Manager at 12:00 PM revealed the facility had mandatory education just recently related to notification of changes, medication refusals, documentation of resident intake, and the use of the care plan. She revealed she passed the post-test with 100% Interview with the Activity Director, on 05/13/2021 at 1:45 PM, revealed he attended mandatory training that addressed a lot of things such as weights, care plans, and supplements. He revealed staff had to take a post test and had to score 100 % on the test. He revealed he scored 100% on the post test. Interview with the MDS Nurse on 05/13/2021 at 2:10 PM revealed she attended recent mandatory education on Significant Weight Loss, Resident Hydration, and the Comprehensive Care Plan, Notification of Changes, Monitoring Nutritional Status, Weight Loss, Medication Refusals and the NAR Committee. She revealed she had to pass a post-test with 100%. Interview with a Unit Manager revealed she had attended mandatory classes related to weight loss, nutrition, notification of changes, care plan implementation, medication administration, intravenous fluids, NAR committee and weekly weights. She revealed she took a posttest as well. Telephonic interview with the physician, on 05/14/2021 at 10:30 AM, revealed the facility had education related to the immediate jeopardies. He revealed he did have input into the education that was provided to the staff. 4. On 04/30/2021, an ad hoc meeting was held with the QAPI. The committee consists of the DON, ADON, MDS Nurse, Nurse Managers, Administrator, Activity Director, SDC, SS, and the Medical Director. During this ad hoc meeting, the QAPI Committee reviewed the information in the IJ Template, audit plan, policies and processes related to change of condition, significant weight loss, missed doses of medication, or supplements, and poor intake, documentation of meal intake, comprehensive care plan process, significant weight loss, nutrition and hydration the education and the post test. No changes to the policies or the corrective plan to remove the immediacy. Record review revealed the facility held a QAPI meeting (Ad Hoc) on 04/30/2021 to discuss the Immediate Jeopardy, and an Allegation of Compliance. Team member's present- DON, Administrator, ADON, Director of Rehabilitation (DOR) Unit Manager, Certified Dietary Manager, Human Resources Specialist, Staff Development Coordinator, and the physician participated via telephone. Continued review revealed a roster titled QA Meeting Sign-In Sheet for 05/03/2021 with an agenda to discuss audits, and overall action plan review. Interview with the Activity Director on 05/13/2021 at 1:45 PM revealed he had attended mandatory training that addressed a lot of things such as weights, care plans, and supplements. He revealed staff had to take a post test and had to score 100 % on the test. He revealed he scored 100% on the post test. Interview with the MDS Nurse on 05/13/2021 at 2:10 PM revealed she had participated in an Ad Hoc Meeting via telephone to discuss the immediate jeopardy template. Interview with a Unit Manager revealed she had participated in an ad hoc meeting on 04/30/2021 to discuss the immediate jeopardy findings. Telephonic interview with the physician on 05/14/2021 at 10:30 AM revealed he had attended an Ad Hoc Meeting with the facility via telephone on 04/30/2021 to discuss the immediate jeopardy template. 5. Review of the individualized care plans revealed residents triggered for a significant weight loss were care planned for nutritional supplements as ordered. Interview with the MDS Nurse on 05/13/2021 at 2:10 PM revealed review of the individual care plan was a part of the audit the facility was doing to ensure nutritional supplements had been documented. Interview with a Unit Manager on 05/13/2021 at 2:30 PM revealed she had reviewed the care plans to ensure nutritional supplements were care planned 6. Record review revealed the facility reviewed and monitored the current residents, who had triggered for significant weight loss, to ensure percentage of diet taken was documented by staff for 05/03/2021 through 05/10/21. 05/13/2021 at 12:15 PM- Interview with the Dining Services Manager on 05/13/2021 revealed every week, the intakes for the residents with significant weight loss are monitored by her as well. She stated the NAR committee may also change interventions, and the RP and the physician would be notified of any changes. Interview with the DON on 05/14/2021 at 10:00 AM revealed she reviewed the resident's intake daily. Interview with a Unit Manager on 05/13/2021 at 2:30 PM revealed she checks the Point of Care (POC) daily to ensure percentage of diet taken had been documented. 7. Record review revealed the MARs of those residents that triggered for a significant weight loss b [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents identified at nutritional risk were monitored and provided nutritional services to meet the needs of the resident to prevent severe weight loss for one (1) of twenty-one (21) sampled residents (Resident #20). The facility admitted Resident # 20 on 09/23/2019. The resident's weight on 12/17/2020 was one-hundred and twenty-seven point six pounds (127.6 lb.) and one-hundred and nineteen point eight pounds (119.8 lb.) on 01/12/2021. This reflected a six point eleven percent (6.11%) weight loss in less than one (1) month and reflective of a severe weight loss. Resident #20 was on a Fortified Regular, Mechanical, Thin diet. According to the facility's policy, individuals with unplanned significant/severe weight loss would receive immediate nutrition intervention to prevent further weight loss, stabilize weight, and/or regain weight if appropriate. Record review revealed from 12/01/2020 to 01/18/2021, the facility did not record the resident's intake for multiple meals. Review of the Medication Administration Record (MAR) revealed from 12/01/2020 to 01/18/2021 the facility did not record the administration of Resident #20's [MEDICATION(S)] tablets (appetite stimulant) for several dosages. Resident #20 had abnormal sodium (high) lab results. The Advanced Registered Nurse Practitioner (ARNP) wrote orders for intravenous (IV) fluids and to repeat the lab (Basic Metabolic Panel/BMP) test. Record review and interview with staff revealed the facility failed to administer the intravenous (IV) fluids and to failed to repeat the lab BMP as ordered by a medical provider. Record review on 09/30/2020 per the Registered Dietician, Resident #20 was to continue with Nutritional at Risk Program (NAR) and also recommended weekly weights for three (3) months to monitor any significant changes. Review of the resident's weight log revealed the resident had not been weighed ten (10) weeks of the three (3) month period. The facility transferred Resident #20 to the hospital on 01/18/2021 and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 was discharged from the hospital on 01/21/2021 with discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 returned to his/her home from the hospital with Hospice Care, and passed away on 01/30/2021. Interview with Resident #20's family member revealed she was appalled at how much weight the resident had lost while living at the facility. She revealed the resident was sent out to an acute care hospital where staff estimated his/her weight to be one hundred (100) pounds. Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on 04/26/2021 and determined to exist on 09/30/2020. The facility's failure to have an effective system in place to ensure each resident received adequate hydration, nutrition and diets to prevent excessive weight loss has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.25 Quality of Care (F692 at S/S of J), 42 CFR 483.10 Quality of Care (F580 at S/S of J), and 42 CFR 483.21 Quality of Care (F656 at S/S of J) and were determined to exist on 09/30/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/03/2021 alleging removal of the Immediate Jeopardy on 05/04/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/04/2021, prior to exit on 05/14/2021, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy and procedure titled, Immediate Temporary Interventions for Unplanned Significant Weight Loss, dated 02/05/2012, revealed individuals with unplanned significant/severe weight loss would receive immediate nutrition intervention to prevent further weight loss, stabilize weight, and/or regain weight if appropriate. Review of the facility's policy and procedure titled, Hydration-Clinical Protocol, dated 09/2017, stated the physician would manage significant fluid and electrolyte imbalance, and at times oral rehydration may suffice. For more severe or complicated fluid and electrolyte imbalance, subcutaneous or intravenous hydration may be needed. The staff would provide supportive measures such as supplemental fluids. The physician and staff would monitor for the subsequent development, progression, or resolution of fluid and electrolyte in at-risk individuals. The physician would adjust treatments based on specific information, lab results, level of consciousness, etc. Further review revealed repeating the Basic Metabolic Panel (BMP) could help track progress in correcting abnormalities. Closed record review revealed the facility admitted Resident #20 on 09/23/2019 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID 19 on 01/08/2021. Closed record review of the Quarterly Minimum Data Set (MDS), dated and signed on 01/08/2021, revealed Resident #20's Brief Interview for Mental Status (BIMS) score was one (1) which indicated the resident was not interviewable. Continued review of the MDS revealed the resident required limited assistance of one person with eating, and the resident consumed a mechanically altered diet. Review of Resident #20's Comprehensive Care Plan, dated 09/30/2020 revealed the focus that Resident #20 had nutritional problem or potential nutritional problem of dehydration related to mechanically altered diet restrictions. The goal(s) included the resident will have gradual weight gain of two (2) to three (3) pounds per month for three (3) months. The resident will show no signs or symptoms of dehydration, and the resident will maintain good oral (PO) intakes of greater than or equal to fifty percent (50%) at most meals and included a target date of 03/10/2021. The interventions included to monitor/record/report to Medical Physician signs and symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: three (3) pounds in one (1) week, greater than 5% in one (1) month, greater than 7.5% in three (3) months, or greater than 10% in six (6) months, provide and serve supplements as ordered: nutrition shake three times a day (TID), and fortified foods, provide and serve diet as ordered, monitor intake and record every meal, and weigh as ordered. Review of the facility's Investigative Summary revealed Resident #20 had been placed on the NAR program in the past (07/2020) to monitor weight loss. Closed record review of a Dietary Progress Note, dated and signed on 09/30/2020 by Registered Dietician (RD) #2, revealed Resident #20's current body weight was one-hundred and thirty one point four pounds (131.4) on 09/03/2020. Further review revealed there had been a fifteen point four percent (15.4%) weight loss noted between 06/12/2020 and 07/14/2020, weight had restored since. The note stated the weight trend showed a decline for four (4) months. The resident's Body Mass Index (BMI) was twenty (20) and low for the resident's age. Continued review revealed it would be beneficial to the resident to have a gradual weight gain of two (2) to three (3) pounds (lbs.) per month. RD #2 recommended nutrition shake three (3) times a day with meals, and continue to monitor the resident in NAR. The RD recommended weekly weights for three (3) months to monitor for any significant changes. Continued review of the Order Summary Report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 10/01/2020, with a start date of 10/05/2020, and an end date 01/05/2021. Review of the Medication Administration Record (MAR)/Treatment Administration Records (TAR) dated 10/2020, 11/2020, 12/2020, and 01/2021 revealed the order for weekly weights for three (3) months every day shift and every Monday with a start date of 10/05/2020. However, review of Resident #20's October 2020 MAR/TAR, and the Weight Log revealed no documentation of the resident's weekly weights on 10/05/2020, 10/19/2020, or 10/26/2020. Review of Resident #20's November 2020 MAR/TAR, and the Weight Log revealed no documentation of the resident's weekly weight on 11/02/2020, 11/09/2020, 11/16/2020, 11/23/2020 or 11/30/2020. Review of Resident #20's December 2020 MAR/TAR and the Weight Log, dated 12/2020, revealed no documentation of the resident's weekly weight on 12/28/2020. Review of Resident #20's January 2021 MAR and Weight Log, dated 01/2021 revealed no documentation of the resident's weekly weight on 01/04/2021. Continued review of Resident #20's 01/2021 Weight Log revealed the resident had been weighed on 01/12/2021. The resident weighed one-hundred and nineteen point eight (119.8) pounds. In comparison to the resident's previous weight of one-hundred and twenty-seven point six (127.6) pounds on 12/17/2020, the resident had lost 6.6% of his/her body weight in less than one month which reflected a severe weight loss. However, the facility did not provide documented evidence that Resident #20 received immediate nutrition interventions to prevent further weight loss, to stabilize weight, and/or regain weight if appropriate, per their policy and procedure. The facility did not follow the resident's individualized care plan related to alteration of nutrition. Interview with Licensed Practical Nurse (LPN) #1, on 04/15/2021 at 10:20 AM, and on 04/20/2021 at 12:19 PM revealed she had been a caregiver for Resident #20, but was no longer employed by the facility. She revealed she did remember the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated she did not remember weighing the resident on 01/12/2021. However, she stated if she had initialed on the MAR/TAR she had weighed the resident, then she weighed the resident. Further interview revealed she could not recall the resident being flagged for weight loss in the Point Click Care (PCC- facility's documentation system) system or if the resident had a significant or severe weight loss on 01/12/2021. She stated if the resident did, she would have notified someone in Management as well as the family. LPN #1 stated anytime a resident had a significant/severe weight loss nursing should always do immediate interventions such as re-weigh the resident, and notify the medical provider and the family. She stated that a significant/severe weight loss could be caused by malnutrition, or failure to thrive. LPN #1 stated staff would need to get to the root of the problem of why a resident had experienced a significant/severe weight loss. She stated if Resident #20 sustained a significant/severe weight loss on 01/12/2021, she would have charted that immediately along with any interventions in the PCC system, but that would all depend on if something crazy had been going on in the Unit. She revealed if a resident had a severe/significant weight loss and no interventions were put in place, harm could occur to the resident. Closed record review of Resident #20's clinical record revealed no documented evidence that staff had identified the 6.11% weight loss in less than one month (12/17/2020 until 01/12/2021), or had reported the weight loss to the medical provider, the DON, the RD, or the family. Interview with the Director of Nursing (DON), on 04/15/2021 at 10:51 AM, revealed she had started working at the facility on 02/01/2021. She revealed anytime a resident had a significant/severe weight loss, the resident should be re-weighed to verify the weight loss. She revealed when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review revealed no documented evidence that the facility reweighed Resident #20 on 01/12/2021. Interview with the Minimum Data Set (MDS) Nurse, on 04/15/2021 at 11:15 AM, revealed she had been the Interim DON in the facility from 12/2020 until the new DON started on 02/2021. She stated she did not really remember Resident #20 and did not recall any staff person alerting her about a severe/significant weight change on 01/12/2021. Further interview revealed if she had known Resident #20 sustained a significant/severe weight loss, she would have alerted the physician, the family, the dietary manager, and the registered dietician immediately. She revealed if a weight decline was not identified early by staff, and reported to the physician, the resident's overall health could decline. Interview with Licensed Practical Nurse #2, on 04/15/2021 at 1:48 PM, revealed if a resident had a significant/severe weight loss, staff should notify the DON, the medical provider, and the family, and document all of the notifications in a progress note as well as complete a Change of Condition which was located in the PCC. However, record review revealed no documented evidence that a Change of Condition related to a severe weight loss had been completed by a nurse on 01/12/2021. Interview with Registered Nurse (RN) #1, on 04/15/2021 at 2:21 PM, and, on 04/19/2021 at 12:31 PM, revealed anytime a resident lost a significant amount of weight, staff should notify the unit manager, the physician, and the family. She revealed it was important to notify the family because staff might be able to collaborate with them on new interventions to help the resident eat more, and gain weight. She revealed once a resident was on NAR, they were weighed every week. RN #1 stated residents on weekly weights needed their weight monitored more closely for changes in weight gain or weight loss. She stated either the nurses or the Certified Nursing Assistant (CNA) would weigh each resident, as instructed by Administration, and input the weight into the PCC. She revealed the PCC computer program would prompt the staff of a weight loss over either a week, or a month. She also stated a Change of Condition should be completed in the PCC as well. Interview with LPN #3, on 04/15/2021 at 2:21 PM, revealed anytime a resident lost a significant/severe amount of weight, the doctor, the family, and the DON should be notified about the change so other interventions could be put into place to help the resident gain weight. She revealed staff should document any notifications or changes made in a progress note. LPN #3 stated if it was not documented, it did not happen. Interview with the Registered Dietician (RD) on 04/15/2021 at 11:47 AM, and, 04/19/2021 at 11:43 AM, revealed she had started working as the RD in the facility the first week of December, 2020 and her role was to monitor and ensure residents had a stable weight. She stated Resident #20 had been added to NAR on 01/14/2021 after he/she sustained a weight loss of 6.11% in thirty (30) days. She revealed she had not been made aware by the facility that Resident #20 had a severe weight loss on 01/12/2021. However, she became aware of the resident's weight loss after reviewing the Monthly Weight Report. She revealed she would have assessed the resident's loss sooner if the facility had made her aware of the weight loss when it occurred. The RD revealed she could have started the resident on new interventions such as a nutritional supplement (Hi-Cal med pass) and ordered labs such as a [CONDITION(S)] Stimulating Hormone (TSH) because it would provide information regarding the functioning of the [CONDITION(S)] which regulates hunger, satiety, protein, and [MEDICATION(S)]. She also stated she would have ordered a glycated hemoglobin (A1C) blood test in order to assess the resident's blood glucose level. The RD stated the purpose of the NAR program was to ensure residents identified at risk for weight loss were monitored weekly on Thursday by the NAR committee. She revealed she was not aware Resident #20 should have been on the NAR program, and did not know the resident was to have his/her weights monitored weekly for three (3) months. Interview with Unit Manager #1, on 04/19/2021 at 1:00 PM, revealed whenever she weighed her residents, she would enter the weight into the PCC system. She revealed the PCC would display a flag and that indicated a resident had a weight loss. Continued interview revealed if the weight loss was significant/severe the first thing she would do would be to re-weigh the resident, and make the medical provider aware of the weight loss. She stated, I would review the resident's progress notes and medications as well as any resident behaviors to try and figure out what could be the reason for the weight loss. Interview with LPN #5, on 04/19/2021 at 2:30 PM, revealed residents at risk for weight loss could be weighed every week, and residents on NAR were usually weighed every week. She revealed once a resident's weight was entered into the PCC system, staff would get an alert if there was an issue with the weight. LPN #5 stated the PCC would also provide information on how much weight a resident had lost or gained in so many days. She revealed anytime a resident triggered for weight loss, the physician and the Administration should be notified to address the weight loss. LPN #5 stated she would also fill out a Change of Condition in the computer system, and this information would go to the twenty-four (24) hour report and could be discussed in the morning meetings as well. She stated staff could refer to the individualized care plan to confirm how often a resident should be weighed, and the Director of Nurses (DON) and/or one of her assistants would give staff a weight list to be completed every week by Wednesday. Interview with the former Staff Development Coordinator (SDC) /Wound Nurse/Infection Preventionist, on 04/22/2021 at 2:00 PM, revealed she was employed by the facility from 03/2020 until 10/2020. She stated there were consistent issues with weekly weights not being done. She stated weekly weights did not have to be ordered by the physician, or the RD but rather how often a resident was weighed may also be up to the discretion of the nursing staff. Further interview revealed weekly weights were obtained on residents because they were losing weight, or had a wound. She stated anytime a resident's weight was entered into PCC that the program would alert if the resident had a three percent (3%) weight loss. She stated if a significant/severe loss of weight was not identified by staff, the resident would become malnourished, and could ultimately die. Interview with Registered Nurse #2, on 04/25/2021 at 11:00 AM, revealed she had previously been employed by the facility to work on the weekends. She stated the facility made staff aware of residents with weight loss through NAR, but in her experience that notification had not always occurred. She revealed staff were also made aware of residents with weight loss through the MAR/TAR because of various supplements/medications that had been ordered for the resident. She revealed the resident's care plan should be updated to include NAR. She stated when staff identified a resident to have a significant/severe weight loss, the physician should immediately be notified of the weight loss because if interventions related to the weight loss were not put into place at that time, a resident might suffer harm. She stated there should be a discontinue order written by one of the NAR staff members whenever a resident was discharged from NAR. Interview with LPN #4, on 04/26/2021 at 1:00 PM, revealed she had been Resident #20's nurse on 01/12/2021, however, she had not been informed by staff of the resident's significant/severe weight loss or she would have immediately notified the physician. She revealed if significant/severe weight loss was not identified and addressed by staff then a resident could get dehydrated, weak, and malnourished and die. Review of Resident #20's MAR/TAR dated 12/2020 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review and revealed the medication had not been administered to Resident #20 on 12/06/2020, 12/07/2020, 12/19/2020, 12/25/2020, or 12/29/2020. Continued review of the MAR/TAR dated 01/2021 revealed Resident #20 had not received [MEDICATION(S)] on 01/02/2021, 01/08/2021or 01/16/2021. Interview with LPN #6, on 04/20/2021 at 12:10 PM, revealed she had quit working at the facility in 01/2021. She revealed she did not recall caring for Resident #20 on 01/08/2021, and had no idea why she did not mark off the [MEDICATION(S)] as given to Resident #20. She stated as she administered medications to each resident, she would initial the MAR and if the resident had refused the medication, she would have made a note in his/her chart as refused, and notified the doctor. She revealed [MEDICATION(S)] was sometimes given as an appetite stimulant. Interview with LPN #7, on 04/20/2021 at 12:30 PM, revealed she had no idea why she did not administer Resident #20's [MEDICATION(S)] on 01/16/2021 at 9:00 PM. She revealed she gets so busy with the residents, and worked a lot of different shifts. LPN #7 revealed she would normally document a reason in the resident's chart regarding why the resident did not receive the medication. She stated [MEDICATION(S)] could help to increase a resident's appetite. Interview with Resident #20's Physician, on 04/19/2021 at 3:06 PM and 04/26/2021 at 10:50 AM, revealed he had been made aware of Resident #20's severe weight loss by a physician at a local Emergency Department (ED) on the day the resident was transferred from the facility (01/18/2021) to the ED with Hypoxemia. He revealed he should have been made aware immediately that the resident had lost a severe amount of weight but he had not been made aware by the facility. He stated Resident #20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He revealed he was not aware the resident had not continued to be monitored in NAR. During continued interview he stated he had not been made aware of the missed [MEDICATION(S)] doses that had been ordered for the resident to increase his/her appetite. He stated he should have been made aware of the missed doses with a reason why the resident did not receive the medication. Closed record review of Resident #20's Amount Eaten and Fluids Document, dated 11/2020, revealed no documentation of the percentage of meals the resident had eaten on 11/02/2020 at 5:00 PM, 11/06/2020 at 9:00 AM, and 12:00 PM, 11/14/2020 at 5:00 PM, 11/18/2020 at 9:00 AM, and 12:00 PM, 11/19/2020 at 9:00 AM, 12:00 PM, and 5:00 PM. Continued closed record review of Resident #20's Amount Eaten and Fluids document, dated 12/2020, revealed no documentation of the percentage (%) of meals the resident had eaten on 12/01/2020 at 12:00 PM, and 5:00 PM; 12/03/2020 at 12:00 PM, and 5:00 PM; 12/4/2020 at 12:00 PM, and 5:00 PM; 12/05/2020 at 12:00 PM, and 5:00 PM; 12/06/2020 at 5:00 PM; 12/07/2020 at 12:00 PM, and 5:00 PM; 12/08/2020 at 9:00 AM, 12:00 PM, and 5:00 PM; 12/09/2020 at 12:00 PM, and 5:00 PM; 12/11/2020 at 12:00 PM, and 5:00 PM; 12/12/2020 at 5:00 PM; and on 12/15/2020 at 12:00 PM, and 5:00 PM. The resident refused the breakfast meal on 12/15/2020. Continued review of the Amount Eaten and Fluids Sheet revealed the resident refused oral fluids on 12/08/2020 other than his/her nutritional shakes. Closed record review of Resident #20's Intake Monitoring for 01/2021 revealed no documentation of the percentage of meals the resident had eaten on 01/04/2021 at 5:00 PM; 01/05/2021 no meal intake had been documented: 01/07/2021 at 12:00 PM, and 5:00 PM; 01/08/2021 at 5:00 PM; 01/11/2021 no meal intake had been documented; 01/13/2021 no meal intake had been documented; and, 01/15/2021 no meal intake had been documented. The resident refused meals on 01/09/2021 at 9:00 AM, and 12:00 PM, and the resident refused all meals on 01/17/2021. Continued review of the Amount Eaten and Fluids Log revealed Resident #20 did not consume any fluids on 01/05/2021, 01/11/2021, 01/13/2021, and 01/15/2021 with the exception of the intake of a Nutrition Shake three times a day. However, the resident refused the Nutrition Shake on 01/13/2021 and 01/15/2021. Interview with LPN #2, on 04/21/2021 at 2:00 PM, revealed anytime a resident did not eat two (2) meals in a row, the doctor and the family should be notified by the staff. She revealed it was important for staff to document how much a resident consumed at each meal because if the intake was not monitored for refusals the resident could lose weight. Interview with Unit Manager #1, on 04/21/2021 at 2:16 PM, revealed when Resident #20 refused meals and fluids, staff should have tried to figure out why he/she was not eating. She revealed staff should have talked with the family, and often supplements that were ordered by the medical provider, and/or the RD. She stated when a resident did not eat or drink for three (3) meals, the physician and the family should be notified, if not sooner, and that other interventions could be put in place in order to prevent the resident from losing more weight. Interview with the Registered Dietician, on 04/15/2021 at 11:47 AM, and 04/19/2021 at 2:00 PM, and revealed she had not assessed Resident #20 in person due to COVID19 restrictions therefore the NAR meetings were held via teleconference. She revealed her role, as the RD, she was to ensure residents maintained a stable weight. She became aware of Resident #20's severe weight loss by review of the Weight Change Report on 01/14/2021. She revealed if staff had notified her sooner that the resident had a severe weight loss, she could have added additional supplements, and other treats such as ice cream and milk. She revealed by her review of Resident #20's percentage of diet and fluids consumed information, it appeared the resident had not eaten all three (3) meals, or any meals on 12/01/2020, 12/03/2020 - 12/09/2020 and 12/11/2020, 12/18/2020, 12/19/2020, 12/20/2020, 12/29/2020, 12/31/2020, 01/05/2021, 01/11/2020, 01/13/2020, and on 01/15/2020. She revealed the RD did not write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed she thought that was more of a nursing order; however, she always looked at that information. She stated if the percentage of meals and oral intake was not documented it was hard to determine exactly what was going on with the resident's nutritional and hydration status. She revealed if a resident was suspected to have severe dehydration based on the resident's intake and labwork, the physician might order IV fluids. Interview with Resident #20's Physician, on 04/19/2021 at 3:06 PM, revealed a decrease in Resident #20's oral intake, and his/her refusal of meals was primarily the reason why Resident #20 had suffered a severe/weight loss and dehydration. He stated he thought the resident was on the NAR program, and was being weighed weekly because of his/her history of weight loss. He revealed staff had not made him aware of the resident's decrease of, or refusal of, sufficient oral intake. The physician stated had staff made him aware of the resident's severe weight loss, and refusal of meals and fluids, other interventions could have been put in place, such as a gastrostomy tube placement for enteral tube feedings, or the resident might have been placed in Palliative Care, and been kept comfortable. Interview with CNA #3, on 04/20/2021 revealed he had provided care to Resident #20 in the past. The CNA stated the resident did not always want to eat, and there were times when the resident had to be fed. CNA #3 stated it was a must to report any refusals of meals to the nurse so the situation could be further addressed. Closed record review of Resident #20's laboratory results, dated 01/12/2021 revealed an elevated sodium level of one-hundred and fifty-two (152) milliequivalent per Liter (mEq/L). (Normal sodium level ranges from 135- 145 mEq/L). Record review revealed Resident #20 was transferred to the hospital on 01/18/2021 and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of the Progress Note, signed and dated by the Advanced Registered Nurse Practitioner (ARNP) on 01/15/2021 at 7:43 AM revealed that, . review of labs for Resident #20 showed acute [CONDITION(S)] most likely related to poor fluid intake. Assessment and Plan- [CONDITION(S)] (A condition where sodium levels in the blood are high): Normal Saline (NS) at seventy-five (75) milliliters (ml), encourage fluids by mouth (PO), and recheck Basic Metabolic Panel (BMP) after the intravenous fluids (IV) have infused. Orders for this visit, NS at seventy-five (75) ml per hour times (x) one liter (due to [CONDITION(S)] and volume depletion), encourage PO fluids, and re-check a BMP after the IV fluids have infused. However, closed record review of the resident's MAR dated 01/2021, revealed no documented evidence of the order for IV fluids as ordered by the ARNP on 01/15/2021. Continued review of Resident #20's clinical record revealed no documented evidence staff had administered the IV fluids to Resident #20, nor had a follow-up BMP lab drawn. Interview with the ARNP, on 04/16/2021 at 11:00 AM, and 04/21/2021 at 12:23 PM, revealed he could not recall if he had or had not discussed the new orders he had written for Resident #20 with the staff. He stated at that time (01/15/2021) his orders were faxed to the facility or e-mailed to the facility via a computer program called Chart Path. The APRN stated the reason Resident #20's sodium level was high could be related to a lack of nutrition and hydration. He stated sodium levels were controlled by water intake, so the less water a resident consumed, the higher his/her sodium level could be. He went on to state by administering a liter of IV fluids to Resident #20, he was hoping to bring the resident's sodium level down to between one-hundred and thirty five (135) and one-hundred and forty-five, which would be considered normal. The ARNP stated he had also ordered a BMP to be drawn after the first liter of IV fluids had been administered to the resident. He stated the plan for the resident had been to repeat the BMP, and if the sodium level was still high, he would order another liter of fluids to be given intravenously. Continued interview revealed if the resident's sodium level continued to rise after the IV fluids, he would have sent the resident to the hospital for further treatment and stabilization. The APRN stated he did not know the IV fluids, or the repeat BMP had not been completed per his orders. Interview with a Chart Path employee, on 04/20/2021 at 10:30 AM, revealed Chart Path had received the order from the ARNP on 01/15/2021, and e-mailed the orders to the facility on [DATE] at 8:24 AM to the Former DON #2, and to the current MDS Nurse. Interview with Former DON #2, on 04/16/2021 at 10:43 AM, revealed at that time, the ARNP's orders were either faxed or emailed via Chart Path to the facility. She stated she did not recall getting Resident #20's orders either way. Continued interview revealed she also indicated she was not the interim DON at that time, she had been doing Staff Development. Interview with the MDS Nurse, on 04/15/2021 at 1:32 PM, revealed she had served as the Interim DON until the beginning of 02/2021, for about one and one half (1.5) months. She stated the facility had made her aware that a progress note with the medical pr [TRUNCATED]

Based on interview, record review, and the facility's policy, it was determined the facility failed to revise the care plan for one (1) of eighteen (18) sampled residents (Resident #6). On 02/20/2020, Resident #6 sustained a fall. However, the facility failed to investigate to identify the root cause or implement additional intervention(s) to prevent another fall. Additionally, on 03/04/2020, the facility discovered the resident face down in the bathroom. The resident was transferred him/her to the hospital. Per record review, the hospital admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy, titled, Fall Management, effective 06/25/2017, revealed a fall risk observation was used to identify individuals who were at high risk for falls, as well as, those individuals who had any risk factors for falls. The policy revealed the Fall Risk Observation was completed upon Admission, Quarterly, Annually, with any Significant Change in Condition and with any fall. Further review of the Fall Management policy revealed a fall may be witnessed, reported by the resident or an observer or identified when a resident was found on the floor or ground. The policy revealed the facility would evaluate and monitor the resident for seventy-two (72) hours post fall. Review of the facility's policy, titled, Fall Risk Assessment, revised March 2018, revealed the staff, with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. Review of the facility's policy, titled, Comprehensive Care Plan, effective January 13, 2018, revealed a Comprehensive Care Plan would be developed for each resident within twenty-one (21) days and no more than seven (7) days after the completion of the comprehensive Minimum Data Set (MDS) Assessment. The policy revealed the Care Planning/Interdisciplinary Team (IDT) was responsible for the review and updating of care plans when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly. The policy revealed the Care Plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #6's closed clinical record revealed the facility admitted the resident on 02/05/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Admission Assessment, dated 02/05/2020, revealed the facility assessed the resident as a moderate fall risk. Review of Resident #6's Nursing Admission Progress Note, dated 02/05/2020, revealed Resident #6 reported he/she was continent of bladder/bowel and used a bedside commode for toileting. However, review of Resident #6's Nursing Progress Notes revealed, on 02/05/2020, the resident smeared feces on the bed and in the bathroom. Review of the resident's Physical Therapy Evaluation, dated 02/06/2020, revealed Resident #6 was evaluated secondary to decreased bilateral lower extremity strength, decreased standing balance, reduced safety awareness, and decreased activity tolerance. Review of the Functional Mobility Assessment Fall Predictors revealed the resident exhibited impulsive ambulation, discontinuity of steps, reduced insight for unsafe situations, and reactive and proactive balance. Review of Resident #6's Nursing Progress Notes revealed the resident fell on [DATE] and 02/12/2020. Continued review of the Nursing Progress Notes revealed no documented evidence the resident was assessed for fall risks post falls on 02/10/2020 or 02/12/2020. Review of Resident #6's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Further review of the MDS revealed Resident #6 required extensive assistance with toileting. The MDS revealed the resident had two (2) fall since admission to the facility. Review of Resident #6's Falls Care Plan, revised 02/13/2020, revealed Resident #6 was at risk for falls related to weakness. Interventions included ensuring the resident's coat was within reach on cold days, reassuring the resident when anxious about breathing by checking oxygen saturation, reminding the resident to ask for assist with transfers, and ensuring floors were free from clutter Review of the resident's Nursing Progress Notes revealed on 02/15/2020, the resident was up constantly from the bed to the bathroom to change his/her brief. Additionally, the Progress Note revealed on 02/18/2020, the resident wet the bed. Further review of the Nursing Progress Notes, dated 02/20/2020, revealed Licensed Practical Nurse (LPN) #4 discovered Resident #6 asleep on the floor. LPN #4's note further revealed the resident would 'be checked' out for putting himself/herself on the floor. Continued review revealed no documented evidence the facility assessed the resident after the fall. Nor was there documented evidence the resident's care plan was revised; and no documented evidence the facility conducted a root cause analysis for the resident's behaviors and falls. Interview was attempted with LPN #4, on 01/27/2021 at 5:08 PM; however, the phone number was no longer in service. Review of Resident #6's Readmission Assessment, dated 03/01/2020, revealed the facility assessed the resident as high risk for falls. Review of the Nursing Progress Notes revealed on 03/02/2020, the resident attempted to void on the floor at bedside. Additional review of the resident's Progress Notes revealed, on 03/03/2020, the facility noted Resident #6 urinated and defecated in the dining room and other common areas of the facility. However, there was no documented evidence the facility assessed and identified the residents toileting needs and/or behavior(s). Nor did the facility initiate interventions to prevent potential falls. Further review of Resident 6's Nursing Progress Notes, dated 03/04/2020 at 2:26 AM, revealed the resident had a Change in Condition. The note stated LPN #2 assessed the resident to have a skin tear on the chin, abrasions to the right and left knee, and limited range of motion to the upper/lower extremities at baseline. Continued review of the Nursing Progress Notes, dated 03/04/2020 at 4:00 AM, revealed staff discovered Resident #6 face down on the bathroom floor with a skin tear to the right elbow and bruising to both knees. The note revealed the resident was disoriented, breathing was labored, and oxygen saturation was seventy-four (74%) percent with four (4) liters of oxygen via nasal cannula. The facility called the Emergency Medical Services (EMS) and transferred the resident to the hospital for evaluation. Additionally, further record review revealed no documented evidence the facility conducted a Fall Investigation or a Root Cause Analysis of the resident's two (2) falls, on 03/04/2020, and no documented evidence the care plan was revised, as per the facility's policy. Review of Resident #6's Emergency Medical Services (EMS) report, dated 03/04/2020, revealed the resident was found lying in bed and nonverbal. The report revealed staff reported they last saw the resident at approximately 9:00 PM on 03/03/2020 when he/she fell in the bathroom and sustained multiple skin tears and a chin abrasion. Review of the resident's Emergency Department (ED) History & Physical (H&P), dated 03/04/2020, revealed the resident fell twice since 9:00 PM and had been confused and somewhat nonverbal since around midnight. Further review revealed the hospital admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with State Registered Nurse Aide (SRNA) #5, on 01/28/2021 at 1:56 PM, revealed Resident #6 tried to toilet unassisted and staff would find the resident on the floor; however, she was not aware of a toileting schedule for the resident. She revealed SRNA's rounded every two (2) hours to check and change residents. She stated residents who were at high risk for falls should be checked more often to ensure their safety. SRNA #5 revealed the care plan stated the resident needed assistance with toileting; however, the resident never used his/her call light to alert staff. Interview with SRNA #3, on 01/28/2021 at 1:32 PM, revealed she rounded at the beginning of the shift and every two (2) hours to ensure residents were in bed, comfortable, and dry. She stated staff usually sat residents at the nurses station to keep an eye on them if they got out of bed unassisted. She stated she read the care plan to determine if a resident was a falls risk; however, she could not recall specifics of Resident #6's care plan. Interview with Licensed Practical Nurse (LPN) #2, on 01/27/2021 at 1:51 PM, revealed Resident #6 was a fall risk and was non-compliant with care, removed his/her oxygen, got up without assistance, and at times urinated in the garbage can. She stated staff kept an eye on Resident #6 after the fall on 03/04/2020; however, she could not recall why she had not revised the care plan and initiated a new intervention. She revealed one-to-one (1:1) supervision or increased monitoring should have been implemented to ensure resident safety due to the resident's non-compliance related to his/her current care plan. The LPN revealed she was not aware of a toileting schedule for Resident #6. Interview with LPN #3, on 01/26/2021 at 3:23 PM, revealed the resident's assigned nurse was responsible for revising the care plan and initiating a new intervention after the resident had a fall. She stated fall interventions would include therapy evaluation, increased toileting checks, ensuring the call light was in reach, and reeducation, if appropriate. Interview with LPN #5, on 01/28/2021 at 7:58 AM, revealed Resident #6's room was located at the end of the hall and she kept the medication cart close to the room so she could check on him/her. She stated she toileted the resident and educated the SRNAs on the resident's call light when she saw the resident get up unassisted. According to LPN #5, Resident #6 should have been on one-to-one (1:1) supervision due to his/her habit of urinating in the trash can. However, she was not aware of any increased supervision. Further interview revealed she increased the resident's supervision on her own; however, she stated it was not part of the resident's care plan. Interview with the Social Services Director (SSD), on 01/26/2021 at 1:42 PM, revealed the Interdisciplinary Team (IDT) reviewed resident falls during the daily clinical meeting and the Unit Manager or DON would revise the care plan as needed. The SSD revealed falls could be a result of a resident trying to go to the bathroom, confusion from being in a new place, or related to medications. She stated it was important to initiate new interventions to ensure resident safety. She further stated she could not recall if the IDT reviewed Resident #6's falls. Interview with the former Director of Nursing (DON), on 02/04/2021 at 4:09 PM, revealed the resident's assigned nurse was responsible for identifying the reason for the fall and revising the care plan with a new intervention to prevent further falls. The DON revealed the interdisciplinary team (IDT) reviewed falls during the daily clinical meeting to identify a root cause and ensure fall interventions were appropriate. The DON revealed the facility should have conducted an investigation to determine what led up to Resident #6 falls; however, she could not recall the circumstances for Resident #6; however agreed the resident's care plan should have been revised. Interview with the Interim DON, on 02/03/2021 at 1:31 PM, revealed the Unit Managers, Minimum Data Set (MDS) Coordinator, and the DON attended the morning clinical meeting and sometimes the SSD. She revealed the IDT reviewed falls during the daily clinical meeting; however, the team did not always review care plans. The Interim DON stated the Unit Manager was responsible for ensuring the care plan was revised. She stated the care plan should be individualized and revised with a new intervention with each fall to prevent further falls. She stated interventions for a resident with poor safety awareness would include reminding the resident to use the call light for assistance, moving the resident closer to the nurses station, and checking on the resident more often. The Interim DON stated she could not recall discussing Resident #6's falls, but stated they should have and revised the resident's care plan accordingly. Interview with the Administrator, on 02/03/2021 at 3:48 PM, revealed the assigned nurse was responsible for revising the care plan immediately after a fall. The Administrator stated the IDT reviewed falls daily to ensure the appropriate interventions were in place. She stated the facility had not identified any issues with care plans; however, they were in the process of educating all nurses on the procedure for falls.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents (Resident #6) environment remained as free of accident hazards to prevent falls. On 02/20/2020, Resident #6 sustained a fall. However, the facility failed to investigate to identify the root cause or implement additional intervention(s) to prevent another fall. On 03/04/2020, the facility discovered the resident face down in the bathroom and transferred him/her to the hospital. Review of the Emergency Department (ED) Discharge Note revealed diagnoses of Severe Sepsis; Closed fracture of the sacrum, Closed fractures of the pubic ramus, Pelvic hematoma, and Bilateral frontal scalp soft tissue hematomas. The findings include: Review of the facility's policy Fall Management, effective 06/25/2017, revealed a fall risk observation was used to identify individuals who were at high risk for falls, as well as those individuals who had any risk factors for falls. The policy revealed the Fall Risk Observation would be completed upon Admission, Quarterly, Annually, with any Significant Change in Condition and with any fall. The policy revealed fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. Further review of the Fall Management policy revealed a fall may be witnessed, reported by the resident or an observer or identified when a resident was found on the floor or ground. The policy revealed the facility would evaluate and monitor the resident for 72 hours post fall. A neurological assessment should be completed on any unwitnessed fall or witnessed fall hitting the head. The policy revealed the facility would complete a fall risk observation to identify any causes that may have contributed to the fall; and complete a root cause analysis and determine an intervention based on the root cause. The policy revealed the facility would implement an intervention (immediately) after the fall, and as the investigation continued, the root cause analysis may trigger additional interventions to the resident's plan of care. Review of the facility's policy Fall Risk Assessment, revised March 2018, revealed the staff, with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. Review of the facility's policy Safety and Supervision of Residents, revised July 2017, revealed the interdisciplinary care team (IDT) would analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The policy revealed the care team would target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Further review revealed implementing interventions to reduce accident risks and hazards would include the following: Communicating specific interventions to all relevant staff; Assigning responsibility for carrying out interventions; providing training, as necessary; Ensuring interventions were implemented; and Documenting interventions. The policy revealed resident supervision was the core component of the systems approach to safety. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the closed clinical record revealed the facility admitted Resident #6 on 02/05/2020 with diagnoses that included Generalized Anxiety Disorder and [CONDITION(S)] ([CONDITION(S)]). Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and determined he/she was interviewable. Further review of the MDS revealed Resident #6 required extensive assistance with toileting. Review of Physician's Orders for Resident #6 revealed an order, dated 02/05/2020, for [MEDICATION(S)] (anti-platelet) 75 mg (milligrams) by mouth once a day. Review of the Admission Assessment, dated 02/05/2020, revealed the facility assessed Resident #6 as a moderate fall risk. Review of Resident #6's Falls Care Plan, revised 02/13/2020, revealed Resident #6 was at risk for falls related to weakness. Interventions included ensuring the resident's coat was within reach on cold days, reassuring the resident when anxious about breathing by checking oxygen saturation, reminding the resident to ask for assist with transfers, and ensuring floors were free from clutter Review of the Nursing Admission Progress Note, dated 02/05/2020, revealed Resident #6 reported he/she was continent of bladder/bowel and used a bedside commode for toileting. Review of the Physical Therapy Evaluation, dated 02/06/2020, revealed Resident #6 was evaluated secondary to decreased bilateral lower extremity strength, decreased standing balance, reduced safety awareness, and decreased activity tolerance. Review of the Functional Mobility Assessment Fall Predictors revealed the resident exhibited impulsive ambulation, discontinuity of steps, reduced insight for unsafe situations, and reactive and proactive balance. Review of the Nursing Progress Notes revealed Resident #6 smeared feces on the bed and in the bathroom on 02/05/2020. Further review revealed the resident was up constantly from the bed to the bathroom to change his/her brief on 02/15/2020; wet the bed on 02/18/2020; and attempted to void on the floor at bedside on 03/02/2020. On 03/03/2020, the facility noted Resident #6 urinated and defecated in the dining room and other common areas of the facility. However, the facility failed to initiate interventions to address Resident #6's toileting needs. Review of Nursing Progress Notes revealed Resident #6 fell on [DATE] and 02/12/2020. Interview with Licensed Practical Nurse (LPN) #5, on 01/28/2021 at 7:58 AM, revealed she was assigned to Resident #6 on 02/12/2020. She revealed she was probably responsible for completing a fall risk assessment after a fall. LPN #5 stated she could not recall if she assessed Resident #6's fall risk on 02/12/2020. However, according to the facility's policy, they were to complete a root cause analysis and determine an intervention based on the root cause of the falls. Further review of the Nursing Progress Notes, dated 02/20/2020, revealed LPN #4 discovered Resident #6 asleep on the floor. The notes stated the facility transferred the resident to the hospital for increased shortness of air (SOA); and, 'to be checked out for putting (himself/herself) on the floor'. Closed record review revealed no documented evidence of an assessment of Resident #6's fall on 02/20/2020. Interview with the Administrator, on 02/05/2021 at 1:48PM, revealed she was unable to locate a facility investigation of Resident #6's fall on 02/20/2020. Interview was attempted with LPN #4, on 01/27/2021 at 5:08 PM; however, the phone number was no longer in service. Review of Resident #6's Readmission Assessment, dated 03/01/2020, revealed the facility assessed the resident as high risk for falls. Review of Resident 6's Nursing Progress Notes, dated 03/04/2020 at 2:26 AM, revealed a Change in Condition. The note revealed LPN #2 assessed the resident with a skin tear on the chin, abrasions to the right and left knee, and limited range of motion to the upper/lower extremities at baseline. Further review revealed the LPN initiated a neuro assessment sheet; however, the facility did not provide a copy of the neuro assessment(s). Continued review of the Nursing Progress Notes, dated 03/04/2020 at 4:00 AM, revealed staff discovered Resident #6 face down on the bathroom floor with a skin tear to the right elbow and bruising to both knees. The note stated the resident was disoriented, breathing was labored, and oxygen saturation was 74% with four (4) liters of oxygen via nasal cannula. The facility activated Emergency Medical Services (EMS) and transferred the resident to the hospital for evaluation. However, closed record review revealed no documented evidence of an assessment of this fall. Review of the Emergency Medical Services (EMS) report, dated 03/04/2020, revealed they arrived on scene at 3:35 AM. Further review of the report revealed EMS found the resident lying in bed and nonverbal. The report revealed staff reported they last saw the resident at approximately 9:00 PM when he/she fell in the bathroom and sustained multiple skin tears and a chin abrasion. According to staff reports, the resident had no complaints at that time. The report revealed staff had discovered the resident approximately one (1) hour prior with altered mental status and non-verbal. Review of the Emergency Department (ED) History & Physical (H&P), dated 03/04/2020, revealed the resident fell twice since 9:00 PM and had been confused and somewhat nonverbal since around midnight. Review of the ED Notes, dated 03/04/2020, revealed diagnoses of Severe Sepsis; Closed fracture of the sacrum, Closed fractures of the pubic ramus, Pelvic hematoma, and Bilateral frontal scalp soft tissue hematomas. Interview with LPN #2, on 01/27/2021 at 1:51 PM, revealed she supervised residents during medication administration and she did would do random walks to ensure the residents were okay. LPN #2 revealed she was assigned to Resident #6 and was charting at the nurses station when staff discovered the resident on the floor on 03/04/2020. She stated the nurse was responsible for a full assessment, notification of the physician/family, and neurological checks if the resident hit their head or had an unwitnessed fall. The LPN stated she was sure she completed neurological checks for Resident #6. Continued interview with LPN #2 revealed Resident #6 was non-compliant with care, removed his/her oxygen, got up without assistance, and at times urinated in the garbage can. According to the LPN, the resident was disoriented, at times, when his/her oxygen level dropped. She stated staff kept an eye on Resident #6 after the fall, after the first fall. However, she could not recall why she had not initiated a new intervention after the first fall. LPN #2 stated 1:1 supervision or increased monitoring should be implemented to ensure resident safety if non-compliance was too bad. Interview with Certified Nursing Assistant (CNA) #5, on 01/28/2021 at 1:56 PM, revealed Resident #6 required assistance with toileting, but never used the call light to notify staff. The CNA revealed staff would find Resident #6 on the floor because he/she always tried to toilet without assistance. She stated the CNAs rounded every two (2) hours to check and change residents. The CNA stated she was not aware of a toileting schedule for Resident #6. She stated residents who were at high risk for falls should be checked more often to ensure their safety. According to the CNA, sometimes the nurse(s) would say a resident slid instead of fell because they did not want to do the paperwork. Interview with CNA #3, on 01/28/2021 at 1:32 PM, revealed she rounded at the beginning of the shift and every two hours to check on all residents and ensure they were in bed, sleeping comfortably, clean and dry. She stated staff usually sat residents at the nurses' station to keep an eye on them if they got out of bed unassisted. According to CNA #3, she found a lot of residents on the floor when she worked at the facility. Interview with LPN #3, on 01/26/2021 at 3:23 PM, revealed the resident's assigned nurse was responsible for assessing the resident, completing neurological checks, if warranted, and documenting the assessment and any injuries in the progress notes. She stated neurological checks should be done every 15 minutes for one (1) hour, every 30 minutes for one (1) hour, every hour for four (4) hours, and then every shift for 72 hours. She stated neuro checks flow sheets were placed in the medical records or the DON's mailbox after it was completed. She stated it was important to assess neurological status after an unwitnessed fall to identify any deviation from baseline. The LPN further revealed a resident on an antiplatelet should be monitored for excess bleeding, bruising, or potential internal injury. Continued interview with LPN #3 revealed the nurse was responsible for initiating a new intervention after a fall. She stated interventions would include therapy evaluation, increased toileting checks, ensuring the call light was in reach, and reeducation if appropriate. Further interview with LPN #5, on 01/28/2021 at 7:58 AM, revealed Resident #6's room was located at the end of the hall. She stated she toileted Resident #6 and educated him/her to use the call light whenever she observed the resident get up unassisted. According to LPN #5, Resident #6 could have been on 1:1 supervision due to his/her habit of urinating in the trash can. Interview with the Physical Therapist (PT), on 01/27/2021 on 9:26 AM, revealed Resident #6 required assistance with transfers and was very impulsive with safety. Interview with the Occupational Therapist, on 01/27/2021 at 9:44 AM, revealed Resident #6 exhibited poor safety awareness and required supervision with toileting to ensure safety. Interview with the Social Services Director (SSD), on 01/26/2021 at 1:42 PM, revealed the Unit Manager (UM) was responsible for the fall investigation. She stated the interdisciplinary team (IDT) reviewed resident falls during the daily clinical meeting. She stated the purpose of the investigation was to determine the root cause of the fall and try to prevent further falls. The SSD revealed falls could be a result of a resident trying to go to the bathroom, confusion from being in a new place, or related to medications. She stated it was important to initiate new interventions to ensure resident safety. The SSD revealed she could not recall if the team discussed Resident #6's falls on 03/04/2020. However, according to the policy the facility was supposed to implement interventions to prevent further falls. Interview with the former Director of Nursing (DON), on 02/04/2021 at 4:09 PM, revealed the assigned nurse was responsible for assessing the resident, completing a fall risk assessment, and neurological checks for a head injury or unwitnessed fall. She revealed the nurse would also determine why the resident fell and initiate an intervention to prevent further falls. The DON stated the interdisciplinary team (IDT) reviewed the fall documentation during the daily clinical meeting to identify the root cause, ensure all documentation was completed properly, and fall interventions were appropriate. The DON revealed the facility should have conducted an investigation to determine what led up to Resident #6 falls. However, closed record review revealed no documented evidence the facility assessed the fall. In addition, there was no documented evidence since 02/13/2020 that new interventions were put in place to prevent further falls. The facility did not provide a copy of the Fall Investigation or root cause analysis for the two (2) falls on 03/04/2020. Interview with the Administrator, on 02/05/2021 at 1:48PM, revealed she was unable to locate a facility investigation of Resident #6's falls on 03/04/2020. Interview with the Interim DON, on 02/03/2021 at 1:31 PM, revealed the UM's, MDS Coordinator, and the DON attended the morning clinical meeting and sometimes the SSD. She revealed the IDT reviewed falls during the daily clinical meeting. She stated the IDT did not always review the fall risk assessment or care plan during the meeting and stated the UM was responsible for ensuring the fall documentation was completed. The DON revealed she could not recall Resident #6. Interview with the former Administrator, on 02/03/2021, on 10:08 AM, revealed the facility tried to address any issues with falls during the morning clinical meeting. The Administrator revealed he was not aware of any issues with falls in the facility. Interview with the Administrator, on 02/03/2021 at 3:48 PM, revealed the IDT reviewed all incident reports during the daily meeting to identify the root cause of a fall(s) and ensure interventions were in place to address fall risk. She stated nursing management was responsible for ensuring fall assessments were completed and coaching staff on the process as needed. Further interview revealed the DON and the Administrator were responsible for ensuring the fall investigation was completed. The Administrator stated the facility had not conducted any staff training for Fall Management since she started working at the facility in December.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (1) of six (6) sampled residents (Resident #4). Resident #4's Admission Minimum Data Set (MDS) Assessment, dated 05/03/18, revealed the facility assessed the resident to require the assistance of two (2) staff for transfers. In addition, the facility assessed the resident as requiring the Sarah Lift (Sit to Stand Mechanical Lift) for transfers per the Lift/Mobility assessment dated [DATE] and 05/24/18. However, the resident's Comprehensive Plan of Care was not developed to indicate how many staff were required to transfer the resident or if any assistive devices were needed for transfers. In addition, interviews with the State Registered Nursing Assistants (SRNAs), revealed they were unaware of where to find documented information related to how a resident was to be transferred. On 06/17/18, SRNA #7 transferred Resident #4 independently from the wheelchair to the bed, without the Sit to Stand Lift, and as the SRNA turned away, the resident fell from the bed. Resident #4 suffered a Laceration of the Oral Cavity requiring sutures; a Contusion of the Right Eyelid and Periocular area; and Medial Subluxation (partial dislocation) of the Right Shoulder. Actual harm was determined to exist on 06/17/18. (Refer to F-689) The findings include: Review of the facility's Policy titled Careplan Procedure undated, revealed the facility must develop a resident center comprehensive care plan for each resident that includes measurable objectives and time tables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. After completing the Minimum Data Set (MDS) Assessment and Care Area Assessment (CAA) portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes to identify problems, causes, contributing factors, and risk factors related to the problems. Further review of the Policy, revealed the Interdisciplinary Team (IDT) must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's strengths, problems, and needs. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in related to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's Comprehensive Care Plan. The Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #4's closed medical record revealed the facility admitted the resident on 04/26/18 with [DIAGNOSES REDACTED]. Review of the Physical Therapy Plan of Care, dated 05/02/18, revealed Resident #4 had functional deficits with transfers and required maximum assistance times two (2) persons and routinely required seventy-five percent (75%) physical assistance of two (2) persons for transfers. Review of the resident's Admission Minimum Data Set (MDS) Assessment, dated 05/03/18 revealed the facility assessed Resident #4 as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Review of Section G 0110: Functional Status, revealed the facility assessed Resident #4 as requiring: extensive assist of two (2) persons for bed mobility; extensive assist of two (2) or more persons physical assistance with transfers; and as ambulation not occurring. Further review of the MDS Assessment, under Section G0300: Balance During Transitions and Walking, revealed the facility assessed the resident as not steady, and only able to stabilize with staff assistance for surface to surface transfer (transfer between bed and chair or wheelchair). Review of the Care Area Assessment (CAA), dated 05/03/18, revealed falls triggered due to Resident #4's physical performance limitations including difficulty maintaining sitting balance, and impaired balance during transitions. The triggering conditions related to balance problems were described as not steady, and only able to stabilize with staff assistance of two (2) persons for surface-to-surface transfer (transfer between bed and chair or wheelchair). Review of the Lift/Mobility Assessment, dated 05/03/18, revealed the facility assessed Resident #4 for the use of a Sit to Stand (STS) Lift (mechanical assistive device used to transfer a person between surfaces by use of electrical or hydraulic power mechanical), to assist with mobility due to being unable to pivot and walk with no or limited physical assistance from staff. Further review revealed the resident could bear weight on at least one (1) leg, was able to follow simple instruction, was able to grip with at least one (1) hand, was able to undergo moderate pressure to the mid to lower back, and weighed less than four hundred (400) pounds. The Assessment revealed the Sara Lift (STS) Lift was required. Review of the Lift/Mobility Assessment, dated 05/24/18, revealed Resident #4 was again assessed for the use of a STS Lift to assist with mobility. Further review revealed the resident could bear weight on at least one (1) leg, was able to follow simple instruction, was able to grip with at least one (1) hand, was able to undergo moderate pressure to the mid to lower back, and weighed less than four hundred (400) pounds. Per the Assessment, the picture of the figure using the STS lift was circled. Review of the Comprehensive Care Plan, undated, revealed Resident #4 was at moderate risk for falls related to weakness. The stated goal with a target date of 08/16/18, revealed the resident would be at reduced risk for injury. The interventions included: keep needed items, water, etc., in reach; and maintain a clear pathway free of obstacles. However, the Care Plan was not developed with individualized interventions to specify the transfer technique to be used, the number of staff required to transfer the resident, or the need for any assistive device for transfers. A copy of Resident #4's Kardex which was a guide to be used as a reference by the SRNAs for providing care, was requested from the Administrator on 10/18/18 at 5:00 PM. However, the Administrator revealed Resident #4 was discharged and the Kardex was not saved into the computer. Review of the Physical Therapy Discharge Summary, dated 06/06/18, revealed Resident #4 could transfer from sit to stand with maximum assist with the bars, required maximum assist for transfers and bed mobility, and was non-ambulatory. Interview with Physical Therapist (PT) #1, on 10/18/18 at 4:05 PM, revealed per the Physical Therapy documentation Resident #4 required maximum physical assistance of two (2) staff for transfers. When questioned about the need for a mechanical lift with transfers, the PT stated it was up to nursing staff to assess for the need for lift usage and type of lift to be used. Review of the Nurse's Note, dated 06/17/18 at 9:25 PM, signed by Registered Nurse (RN) #1, revealed Resident #4's was being placed in bed with two (2) staff assist with the Sara Lift. Per the Note, the resident was set on the side of the bed, the lift was unlocked from the resident, and the resident slid off the bed and hit his/her head. Further review of the Note, revealed upon entering the resident's room, the resident was noted to be lying on his/her right side with his/her head on the ground; blood was dripping from the resident's mouth; and there were (three) contusions and a black eye forming under the right eye. An order was obtained from the Advanced Practice Registered Nurse (APRN) to admit the resident to the emergency room (ER) for evaluation. Review of the Fall Occurrence Report, dated 06/17/18, signed by RN #1, revealed Resident #4 had a witnessed fall on 06/17/18 at 9:25 PM. According to the Report, the resident fell out of bed; had no complaints of pain; and all extremities were free of pain. Continued review revealed the SRNAs had transferred the resident via lift and after disconnecting the resident from the lift, they went to push the lift away from the bed. The SRNAs turned away, and the resident slid off the bed and did hit his/her head with no Loss of Consciousness (L[NAME]). Additional review revealed the Director of Nursing (DON), Family/Responsible Party and Physician were notified. This Report was computerized and did not indicate it was signed or reviewed by the DON or the Administrator. Review of Resident #4's Hospital emergency room (ER) Note, dated 06/17/18 at 8:23 PM, revealed the resident was alert and oriented to person place and time, with no neurological deficit observed. Per the Note, the resident's skin had focal soft tissue swelling with ecchymosis (bruising) in the right supraorbital and infraorbital area (inner and upper portions of the eye). The resident's head had total soft tissue swelling over the right periorbital area (eyelid). The resident's mouth had superficial laceration (a tear or opening in the skin) to the anterior [MEDICATION NAME] mucosa (of the lip) which was approximately 1.5 centimeters in diameter and not separating with some bleeding noted. Per the ER Notes, the resident refused Computed Tomography Scan (CT scan); was educated on concerns of intracranial bleeding, facial fractures, and possible cervical spine fractures; and the family was made aware of the resident's refusal. Continued review of the Hospital ER Note, dated 06/17/18 at 9:50 PM, revealed Resident #4 continued to refuse X-Rays and CT scan. The physician was unsuccessful in stopping the bleeding to the lip, so sutures were placed and [MEDICATION NAME] was placed on a 2 X 2 (bandage) on top of the wound in order to stop the bleeding, which was successful. Continued review revealed the laceration was repaired by skin closure using four (4) sutures. Per the Note, the resident was diagnosed with [REDACTED]. Review of the Hospital ER Coding Summary, dated 06/22/18, revealed Resident #4's [DIAGNOSES REDACTED]. The primary [DIAGNOSES REDACTED]. Review of Resident #4's Nurse's Notes, dated 06/18/18 3:49 AM, revealed the resident returned to the facility from the ER with no new orders. Review of the subsequent Nurse's Notes dated 06/19/18 at 11:59 AM, revealed Resident #4 was noted to have right arm, hand, and shoulder swelling with one (1) plus [MEDICAL CONDITION] to the hand. Resident #4 was unable to raise his/her right hand and an order was obtained from the APRN for an X-Ray of the resident's right arm, hand and shoulder. Review of Resident #4's Radiology Report, of the right arm and right shoulder, dated 06/20/18, revealed the findings indicated: medial subluxation (partial dislocation) of the right shoulder. Review of the Nurse's Notes, dated 06/20/18 at 3:36 PM, revealed the APRN was notified of the X-Ray results and a new order was obtained to sling and swathe the right arm for two (2) weeks. Interview on 10/18/18 at 2:30 PM, and 10/18/18 at 6:00 PM, with SRNA #3, who was assigned to Resident #4 on 06/17/18, at the time of the fall, revealed SRNA #7 alerted her Resident #4 had a fall on the evening of 06/17/18. Per interview, SRNA #7 told SRNA #3 that she (SRNA #7) had transferred Resident #4 independently by standing and pivoting the resident from the wheelchair to the bed. SRNA #3 further stated SRNA #7 told her when she assisted Resident #4 to sit on the side of the bed, she walked away, and when her back was turned, the resident fell to the floor. Further interview revealed after SRNA #7 informed her of this, she (SRNA #3) entered the resident's room while SRNA #7 went to get RN #1. SRNA #3 revealed when she entered Resident #4's room, the resident was in the floor and visibly upset, yelling and crying. She stated she could see a contusion to the resident's head above the right eye already forming. She further stated she did not recall seeing a mechanical lift in the resident's room at the time. Additional interview revealed after RN #1 assessed Resident #4, RN #1, SRNA #3, and SRNA #7, placed a sheet under Resident #4 and lifted him/her back into the bed. Per interview, once the resident was in bed, he/she appeared to be a lot calmer and SRNA #3 noticed there was puffiness and bruising to the resident's eyes. SRNA #3 further stated prior to the resident sustaining the fall, the resident required two (2) people to assist with transfers and a sit to stand lift. The State Agency Representative attempted to contact SRNA #7, and left messages on 10/18/18 at 3:01 PM and 10/18/18 at 5:30 PM; however, the SRNA who no longer worked at the facility, did not return the call. Telephone interview with RN #1, on 10/18/18 at 3:30 PM, confirmed he was the nurse assigned to Resident #4 on 06/17/18 at the time of the fall. Per interview, his documentation reflected exactly what occurred on the night of 06/17/18 regarding Resident #4's fall, and his assessment of the resident after the fall. However, RN #1 stated he had no memory of that night. He further stated nursing was a day in and day out job and a lot of things occurred making it hard to remember everything that happens. When questioned, RN #1 was unable to provide further information. Telephone interview with Resident #4, on 10/18/18 at 3:50 PM, revealed on the night of 06/17/18, he/she had asked SRNA #7 to assist him/her to bed. Resident #4 stated he/she propelled himself/herself to his/her room and asked SRNA #7 if she was going to get another SRNA to help assist him/her into bed. Per interview, SRNA #7 stated, no come on I've got this. Further interview revealed SRNA #7 transferred him/her from the wheelchair by lifting him/her under the arms and transferring him/her to the bed. Resident #4 stated once he/she was seated on the side of the bed, SRNA #7 turned her back and he/she then fell off the bed to the floor. Per interview, Resident #4 stated he/she had to have stitches to his/her mouth. Additional interview revealed after the fall, he/she had pain in his/her shoulder, and his/her right eye was almost swollen shut. Continued interview revealed prior to the fall on 06/17/18, the SRNAs always transferred him/her with two (2) staff and a lift. Telephone interview on 10/18/18 at 4:19 PM, with Resident #4's daughter, revealed on 06/18/18, SRNA #7 came up to her at the facility and apologized for dropping Resident #4. Further interview revealed SRNA #7 admitted she should not have transferred the resident alone and should have had someone present with her during the transfer. In addition, interviews with State Registered Nursing Assistants (SRNAs) revealed they were unaware they could access information on how to transfer a resident per the Electronic Medical Record (EMR) and kiosk (computerized system), and relied on verbal communication from other staff for information related to transfer technique for residents. Interview with SRNA #2, on 10/18/18 at 5:07 PM, revealed the facility used to have Care Plan Sheets the Aides used which provided information on how to transfer residents. She stated the Sheets indicated the assistive devices, to be used and the number of staff required to perform the transfer. However, she stated she had not seen these sheets in a couple of years. Per interview, if she needed to know how someone was transferred now, she would ask the nurse, and if the resident was newly admitted , she would ask therapy staff. Per interview, SRNA #2 did not know if there was information in the kiosk (computerized system) for the SRNAs to review related to transfer technique. Interview with SRNA #4, on 10/18/18 at 5:15 PM, revealed if she needed to know how someone was transferred, she could ask therapy or the charge nurse assigned to the resident. Continued interview revealed SRNA #2 did not know if there was documented information anywhere for review related to transfer technique. Further interview revealed the SRNA did not know if the kiosk provided information related to transfer technique for each resident. Interview with SRNA #6, on 10/18/18 at 5:40 PM, revealed the facility used to have a Care Plan Sheet which listed how residents were to be transferred and how much assistance was needed, but she had not seen this sheet for two (2) years. Additional interview revealed if she needed information on transfer technique for a resident, she would ask the assigned nurse. SRNA #6 revealed she did not know if there was information such as a Kardex in the kiosk to review if needing information related to transfer technique. Interview with Licensed Practical Nurse (LPN) #3, on 10/18/18 at 5:09 PM, revealed specific information regarding patient transfers including how many staff were required to transfer a resident, and if a mechanical lift should be used for transfers should be listed on the Comprehensive Care Plan which could be found in the Electronic Medical Record (EMR). Further interview revealed transfer information should also be on the Kardex which was the reference the SRNAs used in providing care. Per interview the Kardex was in the kiosk, and the SRNAs had access to the information in the kiosk. Interview with RN #2, on 10/18/18 at 5:20 PM, revealed information regarding how a resident was to be transferred was available in the EMR under the Comprehensive Care Plans and under the Kardex which was accessible to both SRNAs and nurses. Per interview, it was important to have specific transfer technique on the Care Plans to indicate the transfer technique, how many staff were required to transfer the resident, or if any assistive devices such as mechanical lifts were to be used. Interview with the MDS Coordinator on 10/18/18 at 6:00 PM, revealed it was her responsibly to complete the MDS Assessments, and develop care plans based on the MDS Assessments, Lift Assessments, Nurses Notes, recommendations from Therapy, physician's orders [REDACTED]. Per interview, the Comprehensive Care Plans were generated from the MDS Assessments through a shell program and she added additional necessary information to the Care Plans. Per interview, the Care Plans should be developed with individualized and specific interventions to ensure staff provided the necessary care and services for each residents' needs. She stated the SRNAs had access to the Kardex which served as a SRNA Care Plan, thorough the computerized kiosk system. Further interview revealed Resident #4's Admission MDS Assessment triggered the CAAS for falls; therefore, a Care Plan was developed related to the resident's risk for falls. However, further interview revealed Resident #4's Comprehensive Care Plan was not developed with individualized and specific interventions to state how many staff were required to transfer the resident, or to state the resident was to be transferred per the sit to stand lift. Interview with the Director of Nursing (DON), on 10/18/18 at 6:50 PM, revealed if Resident #4's Admission MDS Assessment indicated the resident required two (2) staff to assist with transfers, the Comprehensive Care Plan should been developed to include the intervention for two (2) staff to assist with transfers as the Care Plan was derived from the MDS Assessment. Further interview revealed when a resident was admitted , and then quarterly, the RNs completed a Lift/Mobility Assessment for Residents to see if a resident required the assistance of a lift. She stated if Resident #4's Lift/Mobility Assessment indicated the resident needed a sit to stand lift for transfers, the Comprehensive Care Plan should have been developed to include an intervention for the sit to stand lift for transfers. Additional interview revealed the Comprehensive Care Plan and Kardex which were in the EMR should include all necessary information in order for staff to implement necessary interventions for the residents including transfers in an attempt to prevent falls. Per interview, the Care Plan and Kardex information in the EMR was accessible to RNs, LPNs and SRNAs. However, the DON revealed she was unaware SRNAs were not accessing this information. Interview with the Administrator, on 10/18/18 at 7:45 PM, revealed he was unaware of the interventions for transfer technique on Resident #4's Comprehensive Care Plan at the time the resident sustained [REDACTED].#4's Comprehensive Care Plan. He further stated if Resident #4 was assessed as requiring a mechanical lift for transfers, this intervention have been reflected on the resident's Comprehensive Care Plan. Further interview revealed the facility's Care Plans were vague and not that specific related to transfer technique. However, he stated it was his expectation the Care Plans were accurate and provided necessary information in order for the staff to implement interventions to provide safe care.

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure residents receive adequate supervision and assistive devices to prevent accidents for one (1) of six (6) sampled residents (Resident #4). Resident #4 was assessed by the facility to require the assistance of two (2) staff for transfers per the Admission Minimum Data Set (MDS) Assessment, dated 05/03/18. The facility further assessed the resident per the Lift/Mobility assessment dated [DATE], and 05/24/18, as requiring the Sara Lift (Sit to Stand Lift mechanical assistive device used to transfer a person between surfaces by use of electrical or hydraulic power mechanical) for transfers. However, Resident #4's Comprehensive Plan of Care, undated, did not indicate how many staff were required to transfer the resident or if any assistive devices were needed for transfers. On 06/17/18, a State Registered Nurse Assistant (SRNA) transferred Resident #4 independently from the wheelchair to the bed, without the Sit to Stand (STS) Lift, and left the resident sitting on the bed while she turned away. Resident #4 fell from the bed suffering a Laceration of the Oral Cavity requiring sutures; a Contusion of the Right Eyelid and Periocular area; and Medial Subluxation (partial dislocation) of the Right Shoulder. In addition, there was no documented evidence the facility followed the facility's written Policies related to ensuring Incidents and Accidents were investigated by the interdisciplinary team (IDT), as there was no documented evidence an investigation was completed after Resident #4's fall. The facility was unable to submit documented evidence the IDT obtained witness statements, conducted staff interviews with staff working at the time of the fall, or conducted an interview with Resident #4 who was interviewable, in order to gain information related to the circumstances surrounding the fall. In addition, there was no documented evidence of a root cause analysis. Interview with the Director of Nursing (DON) and the Administrator, revealed they were unaware Resident #4 was improperly transferred on 06/17/18. Actual harm was determined to exist on 06/17/18. (Refer to F-656) The findings include: Review of the facility's Policy titled: Falls - Clinical Protocol revised (MONTH) 2012, revealed after a fall, the nurse was to report precipitating factors and details on how the fall occurred. Staff will attempt to define possible cause of the fall within twenty-four (24) hours of the fall. Review of the facility's Policy titled: Incident & Accident Process undated, revealed the purpose of the process was to ensure the facility environment was free from accident hazards over which the facility had control and that each resident received adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines for F-689. Unusual occurrence events, incidents, and accidents noted by facility staff will be reported to the nurse caring for the resident for completion of the Incident and Accident Report. Incidents and Accidents were to be reviewed in daily meeting initially and assigned to appropriate staff for investigation and follow up. Further review of the Policy, revealed Incidents and Accidents were investigated by the interdisciplinary (IDT) team. Assessments and Investigations were done in a systematic manner including identifying and evaluating hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. The IDT will review risks, appropriate interventions and trends for those residents with falls. Follow up for all incidents will be noted and documented in the medical record. Review of Resident #4's closed medical record revealed the facility admitted the resident on 04/26/18 with [DIAGNOSES REDACTED]. Review of the Intermediate Care Plan dated 04/26/18, revealed Resident #4 was totally dependent upon staff to transfer, and required a Hoyer lift (mechanical lift) for transfers. Review of Resident #4's Physical Therapy Plan of Care, dated 05/02/18, revealed the resident had functional deficits with transfers and required maximum assistance times two (2) persons and routinely required seventy-five percent (75%) physical assistance of two (2) persons for transfers. Review of Resident #4's Admission Minimum Data Set (MDS) Assessment, dated 05/03/18 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Review of Section G 0110: Functional Status, revealed the facility assessed the resident as requiring: extensive assist of two (2) persons for bed mobility; extensive assist of two (2) or more persons physical assistance with transfers; and as ambulation not occurring. Continued review of the MDS Assessment, under Section G0300: Balance During Transitions and Walking, revealed the facility assessed the resident as not steady, and only able to stabilize with staff assistance for surface to surface transfer (transfer between bed and chair or wheelchair). Review of Resident #4's Care Area Assessment (CAA), dated 05/03/18, revealed falls triggered due to physical performance limitations including difficulty maintaining sitting balance, and impaired balance during transitions. The triggering conditions with balance problems were described as: not steady, and only able to stabilize with staff assistance of two (2) persons for surface-to-surface transfer (transfer between bed and chair or wheelchair). Review of the Lift/Mobility Assessment, dated 05/03/18, revealed Resident #4 was assessed for the use of a Sit to Stand (STS) Lift to assist with mobility due to being unable to pivot and walk with no or limited physical assistance from staff. Continued review revealed the resident could bear weight on at least one (1) leg, was able to follow simple instruction, was able to grip with at least one (1) hand, was able to undergo moderate pressure to the mid to lower back, and weighed less than four hundred (400) pounds. Per the Assessment, the Sara Lift (STS Lift) was required. Review of the Lift/Mobility Assessment, dated 05/24/18, revealed Resident #4 was again assessed for the use of a STS Lift to assist with mobility. Continued review revealed the resident could bear weight on at least one (1) leg, was able to follow simple instruction, was able to grip with at least one (1) hand, was able to undergo moderate pressure to the mid to lower back, and weighed less than four hundred (400) pounds. Per the Assessment, the picture of the figure using the STS Lift was circled. Review of Resident #4's Comprehensive Care Plan, undated, revealed the resident was at moderate risk for falls related to weakness. The goal with a target date of 08/16/18, revealed the resident would be at reduced risk for injury. Interventions included: keep needed items, water, etc., in reach; and maintain a clear pathway free of obstacles. However, there were no interventions to specify the transfer technique to be used, the number of staff required to transfer the resident, or the need for any assistive device for transfers. A copy of Resident #4's Kardex which was a guide to be used as a reference by the SRNAs in providing care, was requested from the Administrator on 10/18/18 at 5:00 PM. However, the Administrator stated the resident was discharged and the Kardex was not saved into the computer. Review of the Physical Therapy Discharge Summary, dated 06/06/18, revealed the resident could transfer from sit to stand with maximum assist with the bars, required maximum assist for transfers and bed mobility, and was non-ambulatory. Interview with Physical Therapist #1, on 10/18/18 at 4:05 PM, revealed per the Physical Therapy documentation Resident #4 required maximum physical assistance of two (2) staff for transfers. Further interview revealed it was up to nursing staff to assess for the need for lift usage and type of lift to be used. Review of Resident #4's Fall Risk Assessment, dated 06/15/18, revealed the resident scored a twelve (12) indicating the resident was at moderate risk for falls. Further review revealed Resident #4 exhibited loss of balance while standing, and required hands on assistance to move place to place. Review of Resident #4's Nurse's Notes, dated 06/17/18 at 9:25 PM, signed by Registered Nurse (RN) #1, revealed the resident was being placed in bed with two (2) staff assist with the Sara Lift. The resident was set on the side of the bed, the lift was unlocked from the resident, and the resident slid off the bed and hit his/her head. Upon entering the room, the resident was noted to be lying on his/her right side with his/her head on the ground; blood was dripping from the resident's mouth; and there were (three) contusions and a black eye forming under the right eye. Vital Signs were assessed and an order was obtained from the Advanced Practice Registered Nurse (APRN) to admit the resident to the emergency room (ER) for evaluation. Review of the Fall Occurrence Report, dated 06/17/18, completed by RN #1, revealed Resident #4 had a witnessed fall on 06/17/18 at 9:25 PM. Per the Report, the resident fell out of bed; had no complaints of pain; and all extremities were free of pain. Further review revealed the SRNAs had transferred the resident via lift. After disconnecting the resident from the lift, they went to push the lift away from the bed. When the SRNAs turned away, the resident slid off the bed and did hit his/her head with no Loss of Consciousness (L[NAME]). Further review revealed the Director of Nursing (DON), Family/Responsible Party and Physician were notified. This Report was computerized and not signed by the DON or the Administrator. Review of the Hospital emergency room (ER) Notes, dated 06/17/18 at 8:23 PM, revealed Resident #4 was alert and oriented to person place and time, with no neurological deficit observed. The skin had focal soft tissue swelling with ecchymosis (bruising) in the right supraorbital and infraorbital area (inner and upper portions of the eye). The head had total soft tissue swelling over the right periorbital area (eyelid). The mouth had superficial laceration (a tear or opening in the skin) to the anterior [MEDICATION NAME] mucosa (of the lip) which was approximately 1.5 centimeters in diameter and not separating with some bleeding noted. Per the ER Notes, Resident #4 refused Computed Tomography Scan (CT scan); was educated on concerns of intracranial bleeding, facial fractures, and possible cervical spine fractures; and the family was made aware of the resident's refusal. Continued review of the Hospital ER Notes, dated 06/17/18 at 9:50 PM, revealed the resident continued to refuse X-Rays and CT scan. The physician was unsuccessful in stopping the bleeding to the lip, so sutures were placed and [MEDICATION NAME] was placed on a 2 X 2 (bandage) on top of the wound to stop the bleeding, which was successful. Further, the laceration was repaired by skin closure using four (4) sutures. Resident #4 was diagnosed with [REDACTED]. Review of Resident #4's Hospital ER Coding Summary, dated 06/22/18, revealed the admitting [DIAGNOSES REDACTED]. The primary [DIAGNOSES REDACTED]. Review of the Nurse's Notes, dated 6/18/18 3:49 AM, revealed Resident #4 returned to the facility from the ER with no new orders. Review of the Nurse's Notes dated 06/19/18 at 11:59 AM, revealed Resident #4 was noted to have right arm, hand, and shoulder swelling with one (1) plus [MEDICAL CONDITION] to the hand. Per the Note, Resident #4 was unable to raise his/her right hand. Further review revealed an order was obtained from the APRN for an X-Ray of the resident's right arm, hand and shoulder. Review of the Radiology Report, of the right arm and right shoulder, dated 06/20/18, revealed the findings indicated: medial subluxation (partial dislocation) of the right shoulder. Review of the Nurse's Notes, dated 06/20/18 at 3:36 PM, revealed the APRN was notified of X-Ray results and a new order was obtained to sling and swathe the right arm for two (2) weeks. Interview was conducted on 10/18/18 at 2:30 PM, and 10/18/18 at 6:00 PM, with SRNA #3, who was assigned to Resident #4 on 06/17/18 at the time of the fall. SRNA #3 stated SRNA #7 alerted her Resident #4 had a fall on the evening of 06/17/18, and further informed her that she (SRNA #7) had transferred Resident #4 independently by standing and pivoting the resident from the wheelchair to the bed. SRNA #3 further stated SRNA #7 told her she assisted Resident #4 to sit on the side of the bed and walked away, and when her back was turned, the resident fell to the floor. Continued interview revealed after SRNA #7 informed her of this, she (SRNA #3) entered the resident's room while SRNA #7 went to get RN #1. SRNA #3 stated when she entered Resident #4's room, the resident was in the floor and visibly upset, yelling and crying. Per interview, she could see a contusion to the resident's head above the right eye already forming. She stated she did not recall seeing a mechanical lift in the resident's room. Further interview revealed after RN #1 assessed Resident #4, RN #1, SRNA #3, and SRNA #7, placed a sheet under Resident #4 and lifted him/her back into the bed. Continued interview revealed once the resident was in bed, he/she appeared to be a lot calmer and SRNA #3 noticed there was puffiness and bruising to the resident's eyes. SRNA #3 stated prior to the resident sustaining the fall, the resident required two (2) people to assist with transfers and a sit to stand lift. The State Agency Representative attempted to contact SRNA #7 by phone, and a message was left on 10/18/18 at 3:01 PM and 10/18/18 at 5:30 PM; however, the SRNA who no longer worked at the facility, did not return the call. Telephone interview with RN #1, on 10/18/18 at 3:30 PM, revealed he was the nurse assigned to Resident #4 on 06/17/18 at the time of the fall. He stated his documentation reflected exactly what occurred on the night of 06/17/18 regarding Resident #4's fall, and his assessment of the resident after the fall. However, he stated he had no memory of that night. He stated nursing was a day in and day out job and a lot of things occurred making it hard to remember everything that happens. RN #1 was unable to provide further information when questioned. Telephone interview with Resident #4, on 10/18/18 at 3:50 PM, revealed on the night of 06/17/18, he/she had asked SRNA #7 to help him/her to bed. Resident #4 stated the SRNA appeared to not want to assist him/her as she was huffing and rolling her eyes, but said to come on. Resident #4 further stated he/she propelled himself/herself to his/her room and asked SRNA #7 if she was going to get another SRNA to help assist him/her into bed. Per interview, SRNA #7 said no come on I've got this. Continued interview revealed SRNA #7 transferred him/her from the wheelchair by lifting him/her under the arms and transferring him/her to the bed. Per interview, once he/she was seated on the side of the bed, SRNA #7 turned her back and he/she then fell off the bed to the floor. Resident #4 stated he/she remembered crying because there was blood coming from his/her lips. Further interview revealed he/she did refuse to get CT scans and X-Rays at the hospital, but did receive stitches to his/her mouth. Resident #4 stated after the fall, he/she had pain in his/her shoulder, and his/her right eye was almost swollen shut. Per interview, to this day, his/her shoulder and arm still caused him/her pain. Additional interview revealed prior to the fall on 06/17/18, the SRNAs always transferred him/her with two (2) staff and a lift. Telephone interview with Resident #4's daughter, on 10/18/18 at 4:19 PM, revealed on 06/18/18, SRNA #7 came up to her at the facility and apologized for dropping Resident #4. Per interview, SRNA #7 admitted she should not have transferred the resident alone and should have had someone present with her during the transfer. Interview with the DON, on 10/18/18 at 6:50 PM, revealed if Resident #4's Admission MDS Assessment indicated the resident required two (2) persons to assist with transfers, it was her expectation the Comprehensive Care Plan and Kardex would include the intervention for two (2) staff to assist with transfers as the Care Plan was to be derived from the MDS Assessment. She stated when a resident was admitted , the RNs completed a Lift/Mobility Assessment for Residents to see if a resident required the assistance of a lift. Further interview revealed if Resident #4's Lift/Mobility Assessment indicated the resident needed a sit to stand lift for transfers, this information should also have been on the Comprehensive Care Plan and Kardex. Per interview, the Comprehensive Care Plan and Kardex which were in the Electronic Medical Record (EMR) should include all necessary information in order for staff to implement necessary care for the residents. She stated the Care Plan and Kardex information in the EMR was accessible to RNs, LPNs and SRNAs. Further interview with the DON, revealed on 06/17/18, the day of Resident #4's fall, the resident required two (2) persons to assist with transfers and required lift usage of a sit-to-stand lift. Per interview, it was her understanding that on the night of 06/17/18, two (2) SRNAs were assisting Resident #4 to the bed with a sit-to-stand lift. The DON stated after the transfer when the resident was sitting on the bed, the lift was disconnected to the lift pad which the resident was sitting on, and the resident slid off the bed due to poor balance. She stated RN #1, SRNA #4, and SRNA #7 were the staff involved and present with Resident #4 at the time of the fall. She further stated the nurses were the ones who identified the root cause after a fall, because the nurses assessed residents at the time of the fall; however, she was unsure if there was a documented root cause for Resident #4's fall. Further interview revealed the DON was unaware Resident #4 was transferred with only one (1) staff, and no mechanical lift on the evening of 06/17/18. The DON stated the facility's fall documentation for Resident #4 did not reflect that information. However, further interview with the DON, revealed there was no documented evidence the IDT conducted an investigation related to the fall; and no documented evidence of interviews or witness statements from staff involved at the time of the fall in order to identify the root cause of the fall. Interview with the Administrator, on 10/18/18 at 7:45 PM, revealed he was unaware of the interventions for transfer technique on Resident #4's Comprehensive Care Plan at the time of the fall on 06/17/18; however, he stated if the MDS Assessment was coded for the resident to be transferred with the assist of two (2) staff, then this should have been reflected on Resident #4's Comprehensive Care Plan. He further stated if Resident #4 required a mechanical lift for transfers, this should have been reflected on the resident's Comprehensive Care Plan. Continued interview revealed the facility's Care Plans were vague and were not that specific related to transfer technique, but it was his expectation the Care Plans were accurate and provided necessary information in order for the staff to safely care for the residents. Further interview with the Administrator, revealed it was his understanding that on 06/17/18, two (2) SRNAs were assisting Resident #4 to bed with the assistance of a sit-to-stand lift and after releasing the lift sling, the resident slid sideways and landed on the floor. Per interview, this was what RN #1 documented related to the fall, and he knew this to be true as he had interviewed SRNA #3, SRNA #7, and RN #1 after the fall. However, he stated he had no documented evidence the facility had conducted interviews with these staff members. Continued interview revealed he had not learned from staff interviews that Resident #4 was transferred with only one (1) staff, and no mechanical lift the evening of 06/17/18. He stated it was his expectation for staff to follow the facility's policies and procedures regarding falls, and that falls be accurately investigated and documented. Continued interview revealed the IDT was responsible for investigating the root cause of falls; however, there was no documented evidence of an investigation completed by the IDT related to Resident #4's fall and no documented evidence of a root cause analysis.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the residents' responsible party was notified of the resident's scheduled appointment for one (1) of eight (8) sampled residents, Resident #1. Interview with Resident #1's Responsible Party (RP), on [DATE] at 10:00 AM, revealed on [DATE], the resident went to a physician appointment unescorted by facility staff. The RP stated the facility did not notify him of the appointment. He stated after the appointment, the resident left the office unescorted and did not return to the facility. The RP stated the resident's girlfriend notified him the resident was missing, before the facility notified him. Interview with the Police Detective, on [DATE] at 12:40 PM, revealed Resident #1 was found deceased approximately nine (9) miles away from the physician's office, on [DATE] at 4:00 PM. The facility's failure to have an effective system in place to ensure the responsible party was notified of residents' appointments has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency's (SSA) determined the facility completed corrective action prior to the initiation of the SSA's investigation on [DATE]; therefore, the Immediate Jeopardy was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy, Transportation, dated [DATE], revealed the facility would assist the resident with arranging transportation to/from diagnostic appointments when necessary. Should it become necessary to transport a resident to a diagnostic service outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representation and inform them of the appointment. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have difficulty communicating words and finishing thoughts. The MDS stated the resident usually understood others but missed some part/intent of the message. The facility assessed the resident with a Brief Interview for Mental Status score of four (4) out of fifteen (15) and determined the resident not interviewable. Review of Resident #1's Care Plan, dated [DATE], revealed an intervention to contact the family for all the resident's needs. Further review of Resident #1's clinical record revealed the facility listed Resident #1's parent as the responsible party and listed his/her girlfriend as a friend. Interview with the Social Services Director (SSD), on [DATE] at 1:35 PM, revealed Resident #1's Responsible Party had given consent for the girlfriend to take over the care of Resident #1. However, review of Resident #1's clinical record revealed no evidence the responsible party gave consent for the girlfriend to take over the resident's care. The SSD stated nursing informed her on [DATE], after the resident's girlfriend called the facility asking to speak to the resident, that Resident #1 never returned from his/her physician appointment. She stated she called the local hospitals to determine if the resident had been directly admitted from the physician's office and determined he/she had not. The SSD stated she informed the Administrator and Interim Director of Nursing Services first that Resident #1 was missing. She stated the facility kept in contact with the girlfriend because the girlfriend went to the physician's office to look for Resident #1. She stated she notified Resident #1's Responsible Party after speaking to the girlfriend, making calls to hospitals, and notifying facility management. Interview with Resident #1's Responsible Party (RP), on [DATE] at 10:00 AM, revealed he had say so in the care of Resident #1. The RP stated after the nursing facility admitted Resident #1, staff asked him if it was all right to share information with the resident's girlfriend and he agreed. However, that agreement did not mean the facility should not notify him whenever the resident had an appointment. The RP stated most of the time the girlfriend would provide him with updates on the resident's health status and not the facility. He stated there were times he would call the facility himself to find out what was happening with the resident. The RP stated Resident #1's girlfriend notified him the resident never returned to the facility on [DATE], before the facility contacted him. The RP stated he expected the facility to keep him informed of the resident's transfers out of the facility. Review of Resident #1's Nursing Documentation, dated [DATE], revealed the resident had an appointment on [DATE]; however, the resident missed the appointment due to transportation issues. Nursing rescheduled the appointment for [DATE] at 3:00 PM. The nurse notified the physician of the rescheduled appointment; however, did not notify the responsible party of the appointment change. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 2:23 PM, revealed she had rescheduled Resident #1's appointment for [DATE]. She stated she did not remember if she contacted the resident's responsible party; however, she stated the facility's policy directed nursing staff to contact the responsible party regarding appointments. LPN #2 stated it was important to keep the responsible party informed of the care and services provided to the resident. Interview with the Unit Manager (UM), on [DATE] at 8:15 AM, revealed the facility required nursing staff to notify the family of a resident's scheduled appointments. She stated she did not have time to review resident's medical records to determine if nursing staff were actually performing responsible party notification. The UM stated she worked the floor two (2) to three (3) times a week and it was hard to complete her UM duties when she was taking care of residents. She stated it was important to make the responsible party aware of the resident's appointments. Interview with the Interim Director of Nursing Services, on [DATE] at 2:15 PM, revealed it was the responsibility of nursing staff to notify the RP of the resident's appointments. Interview with the Administrator, on [DATE] at 10:24 AM, revealed the facility policy directed staff to notify the resident's RP of appointments. The Administrator stated the facility had contacted the RP regarding sharing Resident #1's medical information with the resident's girlfriend and the RP approved of the request. She stated she believed sharing information regarding Resident #1's appointments with the girlfriend met their policy requirements for RP notification. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Social Services Director began to call the area hospitals, and notified the Administrator, Interim Director of Nursing Services (IDNS), and police, and a missing person report was filed. 2. The Responsible Party (RP) was notified on [DATE]. 3. On [DATE], staff began searching the areas of the clinic to include missions, under bridges, bars, and parking structures. The Administrator and IDNS worked throughout the night heading up the search, communicating with police and regional staff. The search continued throughout the weekend until Monday, [DATE], when the IDNS was notified by the coroner that Resident #1 was found deceased . 4. On [DATE], the facility worked with the Regional Consultant to develop an immediate plan to address the occurrence and on [DATE], the QA Committee (consisting of the Administrator, IDNS, ADNS, Unit Manager, SSD, Activities Director, and Medical Director) met and reviewed the action plan that included revision of the Transportation Policy for diagnostic appointments (non-emergent, non-[MEDICAL TREATMENT] scheduled physician appointments) that included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. The Unit Manager/Charge Nurse/Social Services would call the resident's responsible party to determine if he/she could escort the resident to the appointment and document in the appointment binder by Unit Manager/Charge Nurse/Social Services, if not, the responsible party could send a designee of his/her choice, which confirmed the responsible party/designee was notified of the appointment. Social Services would subsequently call the responsible party/designee to let him/her know what time to be at the facility for the appointment (when the responsible party/designee was to escort). If the responsible party/designee could not attend the appointment, then Social Services did not call him/her. When the responsible party/designee is the escort, Social Services would educate the responsible party that he/she must ride with the resident to and from the appointment. If the responsible party/designee cannot to do this, then Social Services or the scheduler arranges for a staff escort. 5. On [DATE] and [DATE], the Social Services Team, consisting of the Social Services Director (SSD) and Social Services Assistant, reviewed eighty-eight (88) of eighty-eight (88) active residents to validate Brief Interview for Mental Status' (BIMS) were up-to-date and any needed updates were made. 6. On [DATE], the Interdisciplinary Team (IDT) (consisting of the IDNS, the Assistant Director of Nursing Services (ADNS), and the SSD) reviewed current appointments for the week of [DATE] thru [DATE]; to validate residents that had transportation needs met for escorts. 7. On [DATE], the IDT reviewed eighty-nine (89) of eighty-nine (89) active residents in the facility using BIMS, diagnosis, and IDT knowledge of physical needs to determine who could transport to non-emergent physician appointments without an escort. A list of residents who could transport safely was posted in the appointment books as a reference for nurses until a process could be developed and education completed. 8. A Transportation Form was developed on [DATE], and first used on [DATE]. The Unit Manager/Charge Nurse/Social Services fill out the Transportation Form for the appointment and place a copy in the appointment binder so the form can go with the resident to the appointment. 9. When transportation arrives at the facility to take a resident to an appointment and the escort is present, the resident will be signed out of the facility by the responsible party/designee/staff escort. The escort will be given a packet with the Transportation Form and information relating to the resident's care needs to give to the physician's office. The Charge Nurse /Unit Manager/Social Services will document the conveyance of the packet in the medical record. If the packet is not sent with the escort, the Charge Nurse/Unit Manager/ Social Services will immediately contact the physician's office and send the packet electronically. 10. Beginning [DATE], Monday-Friday at the morning stand-up meeting, the IDT began reviewing the process for the appointment binders and Transportation Forms for accuracy and completeness. Residents going to appointments will be discussed to validate the escort needs of the residents. Tools used to aid this discussion included BIMS score, orientation of residents, diagnosis, and physical limitations of the resident. Beginning [DATE], Social Services reported any abnormalities to the QA Committee. 11. Beginning [DATE], the head count protocol for the afternoon Monday-Friday stand down meeting was implemented. At the afternoon stand-down meeting, a head count will be completed by the IDT to confirm that all residents having gone out for appointments have returned. Each resident's return status will be discussed at the meeting. If a resident has not returned from an appointment, the Administrator/designated representative will assign an IDT member to complete follow-up on that resident. That person will report the resident's status to the Administrator/designated representative after speaking with the escort. 12. Beginning [DATE], Monday-Friday at morning meeting and as needed, the IDT reviewed physician's orders [REDACTED]. On the weekends, the nursing supervisor reviewed physician's orders [REDACTED]. On Mondays, the IDT reviews the weekend nurses' interventions and updates the care plans as necessary. 13. On [DATE], the Regional Consultant educated the IDNS, and the IDNS then educated the ADNS, Unit Managers, and Weekend Supervisor, and by [DATE], all active nurses, twenty-three (23) of twenty-three (23), were educated by the IDNS, ADNS, Unit Manager or Weekend Supervisor, to follow-up at the end of a four (4) hour window from the scheduled appointment time to check on the location of the resident and if the resident had not returned to the facility, the nurse was to notify the Unit Manager/Charge Nurse. If a resident had not returned to the facility within four (4) hours of the scheduled appointment time, the Unit Manager/Charge Nurse would then follow-up with the escort or the physician's office to check on the resident's status. The Unit Manager/Charge Nurse would document the follow-up in a nursing note. 14. The ADNS and Unit Manager had a Train the Trainer course (on the action plan) by the IDNS on [DATE], and Weekend Supervisor had a Train the Trainer on [DATE]. 15. Beginning [DATE] and completed on [DATE], education was provided to sixty-two (62) of sixty-two (62) staff including active nurses, certified medication aids, resident care associates, and certified nursing assistants, and department leaders. Staff who were on a leave of absence and/or prn would be educated prior to returning to work in the facility. Agency Staff would be educated prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during orientation period by the IDNS/ADNS/Unit Manager/Nursing Supervisor or Regional Nurse before assuming an assignment. The in-service education included the following: making nursing staff aware of the resident list in the appointment book to utilize as a guide; filling out the transportation form and sending it along with the medical data when the resident was transported to an appointment; nurses documenting out-of-facility appointments to include leaving and returning documentation; requirement of residents/responsible party/designee to sign in and out; providing medical information to caregivers as per care plan; process for scheduling appointment, which included transportation, escort use, and notification of responsible party/designee; to follow-up on residents who were out of the facility for four (4) or more hours; and the stand-down head count and follow-up. 16. On [DATE], the Regional Director of Clinical Operations educated the MDS Nurse regarding reviewing and updating care plans with goals and appropriate interventions related to resident [DIAGNOSES REDACTED]. 17. A question and answer competency review was developed by IDNS and ADNS and given randomly to staff to help measure the staffs' understanding of the information. The IDNS and ADNS utilized a current employee roster for tracking the in-services and exam completion. Those educated via telephone were questioned verbally and those educated in-person completed a written exam given by the IDNS/ADNS/Unit Manager/Weekend Supervisor. 18. On [DATE], the Administrator began daily audits to confirm that the residents who were out on appointments returned safely and timely. 19. A QA Committee Meeting (Administrator, IDNS, Medical Director via phone, MDS Director, Respiratory Therapy, Activities director, Assistant Social Services, Admissions, Social Services Director, Unit Manager, Therapy Director, Scheduler, ADNS, and Regional Nurse) was held on [DATE], to review the audits related to the resident determination process to validate residents' need for escort. The QA Committee reviewed the list of residents who could independently transport safely in the appointment books as a reference for nurses until a process could be developed and education could be completed on the process. The Administrator reported the results of her audit on whether the transported residents had returned safely to the facility to the QA Committee. 20. Beginning [DATE], audits of documentation were completed by the Unit Manager/ADNS/Social Services on documentation of residents leaving the facility to ensure proper signing in and out, with an audit plan of two (2) times a week for eight (8) weeks then two (2) times a month times one (1) month, then a minimum of quarterly. 21. The QA Committee will meet weekly times eight (8) weeks then two (2) times a month times one (1) month and then a minimum of quarterly. The SSA validated the facility implemented the following actions: 1. Interview with the SSD, on [DATE] at 1:35 PM, revealed Registered Nurse (RN) #3 informed her on [DATE], Resident #1 was missing after receiving a call from the resident's girlfriend. The SSD stated Resident #1 had not returned to the facility and his/her whereabouts were not known, at which point she attempted to locate the resident. She stated she made calls to local hospitals and notified the Administrator, the IDNS, and the police. Interview with the Police Detective, on [DATE] at 12:40 PM, revealed the SSD called him on [DATE] at 11:27 PM, and reported Resident #1 had gone to a medical appointment and had not returned to the facility. Interview with the IDNS, on [DATE] at 2:15 PM, revealed the SSD was notified Resident #1 was missing and made calls in an attempt to locate the resident, including calling the Police and hospitals. Interview with the Administrator, on [DATE] at 10:24 AM, revealed the SSD notified her on [DATE] that Resident #1 had not returned to the facility. Review of a Missing Person Report, dated [DATE] at 11:30 PM, revealed the facility notified the police Resident #1 never returned from a physician's appointment. 2. Interview with Resident #1's Responsible Party, on [DATE] at 10:00 AM, revealed he stated he was notified Resident #1 was missing. 3. Interview with the Maintenance Director, on [DATE] at 9:32 AM, revealed on [DATE] at 8:00 AM, he searched for the whereabouts of Resident #1 including inquiring at the physician's office where the resident was last seen and multiple locations where the resident might have gone. The Maintenance Director stated several staff looked for the resident, including the Admissions Director, the Activities Director, the Social Services Assistant, and others. He stated staff communicated with each other by cellular telephone texting and the search continued throughout the weekend. He stated the resident's girlfriend went with him to search multiple places throughout the city including under bridges. Interview with the Activities Director (AD), on [DATE] at 1:14 PM, revealed he received a call at home on [DATE] around 10:30 PM, from the Administrator informing him Resident #1 had not returned to the facility. The AD stated he went with another staff member to search for the resident, including at a Mission serving homeless people, and other places homeless people visited. Interview with the Assistant Director of Nursing Services (ADNS), on [DATE] at 10:45 AM, revealed she coordinated the search for Resident #1. She stated several staff members were directed to search in various locations of the city where they thought the resident might frequent, such as Missions, last known address, and homeless hangouts. Interview with the IDNS, on [DATE] at 2:15 PM, and the Administrator, on [DATE] at 10:24 AM, revealed facility staff worked with the Police while searching for Resident #1 in the community, including at a Mission serving homeless people, through the night and weekend until notified on [DATE], the resident was deceased . 4. Interview with the Regional Consultant, on [DATE] at 12:02 PM, revealed the facility worked with her by telephone conference on [DATE]. She directed the IDNS and ADNS to hold a QA meeting, discuss problems including transportation problems, update policies, and educate staff. Interview with the Maintenance Director, on [DATE] at 9:22 AM, revealed he attended the QA committee meeting on [DATE]. Interview with the AD, on [DATE] at 1:14 PM, revealed he attended the QA committee meeting on [DATE]. Interview with the IDNS, on [DATE] at 2:15 PM, and the ADNS, on [DATE] at 10:00 AM, revealed they attended the QA Committee meeting on [DATE], and discussed the event set forth in the notice of Immediate Jeopardy and developed a plan of action. Interview with the Medical Director, on [DATE] at 3:28 PM, revealed he attended the QA Committee meeting on [DATE], and discussed the action plan regarding Resident #1. Interview with the UM, on [DATE] at 2:43 PM, the Weekend Supervisor/Charge Nurse, on [DATE] at 10:25 AM, and the SSD, on [DATE] at 11:40 AM, revealed they would be responsible for making calls to the responsible party to determine if they could escort the resident to the appointment. If not able to escort, the responsible party could send a designee of his/her choice. The information would be documented in the appointment binder. Continued interview with the SSD, on [DATE] at 11:40 AM, revealed she would make subsequent calls to the responsible party/designee to let them know what time to be at the facility for the appointment. Social Services would arrange for an escort. If the responsible party would be escorting, Social Services would educate them regarding the process and if not willing to follow the process, an escort would be arranged. Interview with Administrator, on [DATE] at 3:45 PM, and the SSD, on [DATE] at 11:40 AM, revealed they attended the [DATE] QA Committee meeting and discussed the incident with Resident #1 and developed an action plan. Review of the QA Committee Meeting sign-in sheet, dated [DATE], revealed the IDNS, Administrator, AD, Maintenance Director, Medical Director, and several other staff met to discuss/review action plans. Review of the Transportation Policy, revised [DATE], revealed the policy revisions included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. 5. Interview with the SSD, on [DATE] at 11:40 AM, revealed she and the Social Services Assistant reviewed resident BIMS scores and completed updates to resident assessments on [DATE] and [DATE]. Interview with the Social Services Assistant, on [DATE] at 10:15 AM, revealed she and the SSD reviewed BIMS scores on [DATE] and [DATE], and completed updates. Review of facility documentation, dated [DATE] and [DATE], revealed eighty-eight (88) of eighty-eight (88) residents BIMS were audited to validate they were up to date. 6. Interview with the IDNS, on [DATE] at 2:15 PM, the ADNS, on [DATE] at 10:00 AM, and the SSD, on [DATE] at 1:55 PM, revealed on [DATE], they reviewed the appointment book for [DATE] through [DATE], to validate residents that had transportation needs had escorts. 7. Interview with the IDNS, on [DATE] at 2:15 PM, the ADNS, on [DATE] at 10:00 AM, and the SSD, on [DATE] at 1:55 PM, revealed during the Interdisciplinary Team (IDT) meeting on [DATE], they reviewed eight-nine (89) of eighty-nine (89) residents using their BIMS, diagnosis, and IDT knowledge of physical needs, to determine who could transport to non-emergent physician appointments without an escort. Review of the transportation binders, on [DATE] at 2:43 PM, revealed the binders contained a reference list of residents who could transport to appointments without an escort until a process could be developed and education completed. Interview with LPN #4, on [DATE] at 3:40 PM, and LPN #2, on [DATE] at 11:55 AM, revealed they were made aware of the list in the appointment book to utilize as a guide. Interview with Administrator, on [DATE] at 3:45 PM, revealed a reference list for nurses of residents who could go to appointments unescorted was placed in the appointment binders on the units. 8. Interview with LPN #2, on [DATE] at 2:38 PM, and LPN #3, on [DATE] at 3:32 PM, revealed they were to ensure a copy of the Transportation Form was sent with the resident when they went out to an appointment. Interview with the Weekend Supervisor, on [DATE] at 10:25 AM, and the UM, on [DATE] at 8:15 AM, revealed the Transportation Form would be filled out and sent along with the medical data when the resident was transported to an appointment. They both stated they trained the nursing staff to ensure the form went with the residents. Interview with the SSD, on [DATE] at 11:40 AM, and LPN #4, on [DATE] at 3:40 PM, revealed the facility developed a Transportation Form on [DATE], for them to fill out when residents were scheduled appointments. The form would be placed in the appointment binder so a copy would go with the resident at time of the appointment. Review of the Transportation Binders on [DATE], revealed copies of Transportation Forms were present. 9. Review of Resident #6 and #8 Release of Responsibility during Leave of Absence Sheet, undated, on [DATE], revealed residents' responsible parties were to sign the resident in and out on the sheet when going out for appointments. Interview with CNA #3, on [DATE] at 11:25 AM, revealed she must sign a resident in and out when escorting to an appointment, take a packet of information with her when she escorted a resident to an appointment, and give the packet to the physician. Interview with LPN #3, on [DATE] at 3:32 PM, revealed they were to ensure a copy of the Transportation Form was sent with the resident when they went out to an appointment. Interview with LPN #2, on [DATE] at 11:48 AM, revealed she was trained to print and send the residents face sheet/transfer sheet, a blank physician's progress note, Medication Administration Record [REDACTED]. Interview with the UM, on [DATE] at 2:43 PM, the Weekend Supervisor/Charge Nurse, on [DATE] at 10:25 AM, and the SSD, on [DATE] at 11:40 AM, revealed they would document the conveyance of the packet in the medical record. If the packet was not sent with the escort, they would immediately contact the physician's office and send the packet electronically. 10. Observation of the IDT morning meeting, on [DATE] at 9:10 AM, and [DATE] at 9:26 AM, revealed the team reviewed the appointment binders and transportation forms for completeness and accuracy. Resident escort needs for appointments were discussed. The team used resident BIMS, orientation, diagnosis, and physical limitations to make decisions. Interview with the SSD, on [DATE] at 11:40 AM, revealed she was responsible for reporting any abnormalities related the appointment binders and transportation forms to the QA committee meeting. She stated there were no abnormalities to report. Review of the IDT morning meeting documents revealed the IDT began the process of reviewing transportation forms and discussing residents escort needs on [DATE]. 11. Observation of the IDT Stand Down meeting, on [DATE] at 4:05 PM, revealed the Head Count protocol was implemented and discussed to ensure residents out on appointments were accounted for and follow-up was assigned. Interview with the Administrator, on [DATE] at 3:44 PM, revealed she conducted the Head Count Protocol at the stand down meeting each afternoon to ensure all residents were accounted for, and if still at an appointment, she assigned a staff member to follow-up to ensure the resident returned safely. 12. Observation of the morning IDT meeting, on [DATE] at 9:38 AM, revealed the team discussed physician orders [REDACTED]. Interview with the Weekend Supervisor, on [DATE] at 10:25 AM, revealed she reviewed physician orders [REDACTED]. Interview, on [DATE] at 9:38 AM, with the IDNS, SSD, and UM, revealed on Mondays, they reviewed the weekend nurses' interventions and updated care plans as necessary. 13. Interview with the IDNS, on [DATE] at 2:15 PM, and the Regional Consultant, on [DATE] at 12:02 PM, revealed the Regional Consultant and IDNS worked together by telephone conference early on [DATE]. The consultant stated she educated the IDNS by phone on the immediate action plan. Interview with the ADNS, on [DATE] at 10:45 AM, the IDNS, on [DATE] at 2:15 PM, the UM, on [DATE] at 8:15 AM, and the Weekend Supervisor, on [DATE] at 10:25 AM, revealed they educated twenty-three (23) nursing staff by [DATE], to follow-up at the end of a four (4) hour window to check on the location of the resident. They all stated staff was trained to notify the Unit Manager/Charge Nurse if the resident did not return from the appointment. Interview with LPN #2, on [DATE] at 2:38 PM, and LPN #3, on [DATE] at 3:32 PM, revealed they were trained to follow-up with the physician's office or the escort if the resident was not back in the facility after four (4) hours and to notify the Unit Manager/Charge Nurse. Interview with LPN #5, on [DATE] at 10:50 PM, revealed if a resident had not returned from an appointment after four (4) hours, she was to follow-up with the physician's office and notify the UM. 14. Interview with the IDNS, on [DATE] 2:15 PM, revealed she completed Train the Trainer education with the Weekend Supervisor, ADNS, and the UM, on [DATE] and [DATE]. Interview with the Weekend Supervisor, on [DATE] at 10:25 AM, and the UM, on [DATE] at 8:15 AM, revealed the IDNS trained them to train others on the action plan. Interview with the ADNS, on [DATE] at 3:25 PM, revealed she was trained by the IDNS regarding the action plan. 15. Interview with the IDNS, on [DATE] at 2:15 PM, and the ADNS, on [DATE] at 10:00 AM, revealed education was completed for sixty-two (62) staff, which included all Licensed Practical Nurses (LPN), Registered Nurses (RN), UMs, medication aides, nursing assistants (CNA) and department heads. Review of facility education sign in sheets, dated [DATE], [DATE], [DATE], and [DATE], revealed sixty-two (62) staff members, consisting of active licensed nurses, certified medication aides, nursing aides, and department leaders, received the education. Interview with LPN #2, on [DATE] at 2:38 PM, and LPN #3, on [DATE] at 3:32 PM, revealed they were required to document in the resident's clinical record when they left and came back from an appointment, along with signing the resident in and out and providing medical information to the caregivers. Interview with LPN #4, on [DATE] at 3:40 PM, revealed she was trained on the revised Transportation Policy. Interview with CNA #4, on [DATE] at 12:00 PM, and LPN #2, on [DATE] at 11:55 AM, revealed they were trained regarding the need for the responsible party/designee/staff escort to sign the resident in and out of the facility

Based on interview, record review, and review of the facility's policy and the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to have an effective system in place to ensure care plan interventions were implemented for one (1) of eight (8) sampled residents, Resident #1. Record review revealed the facility assessed Resident #1 as cognitively impaired and determined the resident had difficulty communicating with others. Resident #1's Care Plan revealed the resident had impaired cognition and thought processes with interventions that directed staff to supervise the resident as needed and communicate with the resident, family, and other caregivers regarding his/her capabilities and needs. On [DATE], the facility sent Resident #1 to a physician's appointment, unescorted by facility staff, via a taxi. Review of Resident #1's [MEDICATION NAME] Consult documentation, dated [DATE], revealed the Physician's Assistant noted the resident had difficulty speaking and the assessment was difficult as he/she was not a good historian, and no family was with the resident. Interview with the Interim Director of Nursing revealed she had spoken with Resident #1's girlfriend around 5:00 PM, and determined the resident was unescorted while at the physician's appointment; however, she did not follow-up with the resident or the physician's office after the notification. The Administrator stated the facility determined the resident exited the physician's office alone, in his/her wheelchair, at 5:41 PM, and around 9:00 PM, the resident's girlfriend called the facility asking to speak to the resident. At that time, nursing staff determined the resident went to the physician's appointment without an escort and should have returned to the facility. Interview with the Police Detective revealed Resident #1 was found deceased approximately nine (9) miles away from the physician's office, on [DATE] at 4:00 PM. In addition, the resident's Responsible Party was never notified of the resident's appointment on [DATE], per the plan of care. The facility's failure to have an effective system in place to ensure care plan interventions were implemented related to cognitive and communication impairment has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency (SSA) determined the facility completed corrective action prior to the initiation of the SSA's investigation on [DATE]; therefore, the Immediate Jeopardy was determined to be Past Immediate Jeopardy. The findings include: Interview with the Interim Director of Nursing Services, on [DATE] at 2:15 PM, revealed the facility referenced the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) process regarding the implementation of the plan of care. Review of the RAI 3.0 User's Manual, dated [DATE], Chapter 4, pages ,[DATE] to ,[DATE], revealed the comprehensive care plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Review of the facility's policy, Transportation, dated [DATE], revealed the facility would assist the resident with arranging transportation to/from diagnostic appointments when necessary. Should it become necessary to transport a resident to a diagnostic service outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representation and inform them of the appointment. Should it become necessary for the facility to provide transportation, the Social Service Designee would be responsible for arranging the transportation through the business office. A member of the nursing staff, or social services, may accompany the resident to the appointment when the resident's family was not available if the resident is not alert or has significant personnel needs. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have difficulty communicating words and finishing thoughts. The MDS stated the resident usually understood others but missed some part/intent of the message. The facility assessed the resident to need the extensive assistance of two (2) staff when transferring between surfaces, performing personal hygiene, and toilet use. The resident was frequently incontinent of urine and always incontinent of bowel. The facility assessed Resident #1 with a Brief Interview for Mental Status score of four (4) out of fifteen (15) and determined the resident not interviewable. Review of Resident #1's Care Plan, dated [DATE], revealed the resident had impaired cognition and thought processes with interventions that directed staff to break tasks into one-step at a time increments, cue, reorient, and supervise the resident as needed. In addition, staff was to communicate with the resident, family, and other caregivers regarding his/her capabilities and needs with an intervention to contact the family for all the resident's needs. Review of Resident #1's [MEDICATION NAME] Consult documentation, dated [DATE], revealed the Physician's Assistant (PA) noted the resident was not very aware of his/her medical condition. The PA noted it was unclear if Resident #1's slurred speech and forgetfulness was due to brain bleed or to Hepatic [MEDICAL CONDITION]. The consult noted it was difficult to assess the resident as he/she was a poor historian and no family was with him/her at the appointment. Interview with Resident #1's Responsible Party (RP), on [DATE] at 10:00 AM, revealed the resident went to a physician's appointment on [DATE], without a facility staff escort. The RP stated the facility did not notify him of the appointment and after the appointment, the resident left the office unescorted and did not return to the facility. Interview with Certified Nursing Assistant (CNA) #2, on [DATE], at 11:15 AM, revealed Resident #1 was confused and forgetful at times. CNA #2 stated the resident would cry at times because he/she could not get his/her words out when trying to communicate with others. She stated she assisted Resident #1 with getting dressed on the afternoon of [DATE], for a physician appointment and then transported him/her to the front lobby in his/her wheelchair to wait for the taxi to transport to him/her to the appointment. The CNA stated if staff did not communicate resident care needs with other caregivers, such as physician office caregivers, resident needs might not be met. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 8:59 AM, revealed Resident #1 was confused at times and had trouble expressing himself/herself due to a stroke. LPN #1 stated the resident would get frustrated because he/she could not get his/her words out. She stated the resident had a doctor's appointment on [DATE] for build-up of fluid in the abdomen. She stated the resident went to the appointment unescorted by facility staff and went missing after the appointment. According to LPN #1, the resident was later found dead near a railroad track. LPN #1 stated she had not reviewed Resident #1's plan of care and could not say what interventions staff should have implemented. She stated she could not speak to Resident #1's specific care plan interventions related to supervision. However, the plan of care directed staff in the care of the resident and if not followed, harm could come to the resident. Interview with the Director of Rehabilitation (DOR), on [DATE] at 10:38 AM, revealed Resident #1 was cognitively impaired, had poor safety awareness, and was confused and not oriented to where he/she was at times. She stated the resident used a wheelchair for mobility and at times, would use a walker. She stated it was not safe for the resident to stand unassisted by staff because he/she was at risk for falls. The DOR stated the facility transported the resident to a physician's appointment without an escort on [DATE]. She stated the resident's girlfriend was supposed to meet the resident at the physician's office; however, the girlfriend had car trouble and never made it to the appointment. Interview with the Unit Manager, on [DATE] at 8:15 AM, revealed the facility failed to provide Resident #1 with the necessary services to meet his/her needs related to escorting the resident to and from physician appointments. She stated she did not arrange for Resident #1 to be supervised by staff during the ride to and from the physician's office or to stay with the resident in case the girlfriend did not meet the resident at the office. She stated following Resident #1's care plan interventions related to staff communicating with other caregivers, such as the caregivers at a physician's office, regarding Resident #1's capabilities and care needs, was necessary to meet the resident's needs. Interview with the Interim Director of Nursing Services (IDNS), on [DATE] at 2:15 PM, revealed she had just started her position on [DATE], and was in orientation when she received a call around 5:00 PM from Resident #1's girlfriend. The IDNS stated the girlfriend informed her that she was not able to attend Resident #1's appointment due to car trouble and wanted to know if the resident had made it back to the facility. The IDNS stated after review of Resident #1's medical record and plan of care, she determined the resident had severe cognitive impairment due to a stroke, history of [MEDICAL CONDITION] requiring a breathing machine, had a feeding tube in place, and required a wheelchair for mobility. She stated residents could be transported safely in a taxi to and from appointments alone if a family member met the resident at the office; however, the facility's policy stated a member of the nursing staff, or social services, may accompany the resident to the appointment when the resident's family was not available and if the resident was not alert or had significant personal needs. She stated it was important for the facility to ensure the resident's plan of care was followed to ensure needs were met. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Social Services Director began to call the area hospitals, and notified the Administrator, Interim Director of Nursing Services (IDNS), and police, and a missing person report was filed. 2. The Responsible Party (RP) was notified on [DATE]. 3. On [DATE], staff began searching the areas of the clinic to include missions, under bridges, bars, and parking structures. The Administrator and IDNS worked throughout the night heading up the search, communicating with police and regional staff. The search continued throughout the weekend until Monday, [DATE], when the IDNS was notified by the coroner that Resident #1 was found deceased . 4. On [DATE], the facility worked with the Regional Consultant to develop an immediate plan to address the occurrence and on [DATE], the QA Committee (consisting of the Administrator, IDNS, ADNS, Unit Manager, SSD, Activities Director, and Medical Director) met and reviewed the action plan that included revision of the Transportation Policy for diagnostic appointments (non-emergent, non-[MEDICAL TREATMENT] scheduled physician appointments) that included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. The Unit Manager/Charge Nurse/Social Services would call the resident's responsible party to determine if he/she could escort the resident to the appointment and document in the appointment binder by Unit Manager/Charge Nurse/Social Services, if not, the responsible party could send a designee of his/her choice, which confirmed the responsible party/designee was notified of the appointment. Social Services would subsequently call the responsible party/designee to let him/her know what time to be at the facility for the appointment (when the responsible party/designee was to escort). If the responsible party/designee could not attend the appointment, then Social Services did not call him/her. When the responsible party/designee is the escort, Social Services would educate the responsible party that he/she must ride with the resident to and from the appointment. If the responsible party/designee cannot to do this, then Social Services or the scheduler arranges for a staff escort. 5. On [DATE] and [DATE], the Social Services Team, consisting of the Social Services Director (SSD) and Social Services Assistant, reviewed eighty-eight (88) of eighty-eight (88) active residents to validate Brief Interview for Mental Status' (BIMS) were up-to-date and any needed updates were made. 6. On [DATE], the Interdisciplinary Team (IDT) (consisting of the IDNS, the Assistant Director of Nursing Services (ADNS), and the SSD) reviewed current appointments for the week of [DATE] thru [DATE]; to validate residents that had transportation needs met for escorts. 7. On [DATE], the IDT reviewed eighty-nine (89) of eighty-nine (89) active residents in the facility using BIMS, diagnosis, and IDT knowledge of physical needs to determine who could transport to non-emergent physician appointments without an escort. A list of residents who could transport safely was posted in the appointment books as a reference for nurses until a process could be developed and education completed. 8. A Transportation Form was developed on [DATE], and first used on [DATE]. The Unit Manager/Charge Nurse/Social Services fill out the Transportation Form for the appointment and place a copy in the appointment binder so the form can go with the resident to the appointment. 9. When transportation arrives at the facility to take a resident to an appointment and the escort is present, the resident will be signed out of the facility by the responsible party/designee/staff escort. The escort will be given a packet with the Transportation Form and information relating to the resident's care needs to give to the physician's office. The Charge Nurse /Unit Manager/Social Services will document the conveyance of the packet in the medical record. If the packet is not sent with the escort, the Charge Nurse/Unit Manager/ Social Services will immediately contact the physician's office and send the packet electronically. 10. Beginning [DATE], Monday-Friday at the morning stand-up meeting, the IDT began reviewing the process for the appointment binders and Transportation Forms for accuracy and completeness. Residents going to appointments will be discussed to validate the escort needs of the residents. Tools used to aid this discussion included BIMS score, orientation of residents, diagnosis, and physical limitations of the resident. Beginning [DATE], Social Services reported any abnormalities to the QA Committee. 11. Beginning [DATE], the head count protocol for the afternoon Monday-Friday stand down meeting was implemented. At the afternoon stand-down meeting, a head count will be completed by the IDT to confirm that all residents having gone out for appointments have returned. Each resident's return status will be discussed at the meeting. If a resident has not returned from an appointment, the Administrator/designated representative will assign an IDT member to complete follow-up on that resident. That person will report the resident's status to the Administrator/designated representative after speaking with the escort. 12. Beginning [DATE], Monday-Friday at morning meeting and as needed, the IDT reviewed physician's orders [REDACTED]. On the weekends, the nursing supervisor reviewed physician's orders [REDACTED]. On Mondays, the IDT reviews the weekend nurses' interventions and updates the care plans as necessary. 13. On [DATE], the Regional Consultant educated the IDNS, and the IDNS then educated the ADNS, Unit Managers, and Weekend Supervisor, and by [DATE], all active nurses, twenty-three (23) of twenty-three (23), were educated by the IDNS, ADNS, Unit Manager or Weekend Supervisor, to follow-up at the end of a four (4) hour window from the scheduled appointment time to check on the location of the resident and if the resident had not returned to the facility, the nurse was to notify the Unit Manager/Charge Nurse. If a resident had not returned to the facility within four (4) hours of the scheduled appointment time, the Unit Manager/Charge Nurse would then follow-up with the escort or the physician's office to check on the resident's status. The Unit Manager/Charge Nurse would document the follow-up in a nursing note. 14. The ADNS and Unit Manager had a Train the Trainer course (on the action plan) by the IDNS on [DATE], and Weekend Supervisor had a Train the Trainer on [DATE]. 15. Beginning [DATE] and completed on [DATE], education was provided to sixty-two (62) of sixty-two (62) staff including active nurses, certified medication aids, resident care associates, and certified nursing assistants, and department leaders. Staff who were on a leave of absence and/or prn would be educated prior to returning to work in the facility. Agency Staff would be educated prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during orientation period by the IDNS/ADNS/Unit Manager/Nursing Supervisor or Regional Nurse before assuming an assignment. The in-service education included the following: making nursing staff aware of the resident list in the appointment book to utilize as a guide; filling out the transportation form and sending it along with the medical data when the resident was transported to an appointment; nurses documenting out-of-facility appointments to include leaving and returning documentation; requirement of residents/responsible party/designee to sign in and out; providing medical information to caregivers as per care plan; process for scheduling appointment, which included transportation, escort use, and notification of responsible party/designee; to follow-up on residents who were out of the facility for four (4) or more hours; and the stand-down head count and follow-up. 16. On [DATE], the Regional Director of Clinical Operations educated the MDS Nurse regarding reviewing and updating care plans with goals and appropriate interventions related to resident [DIAGNOSES REDACTED]. 17. A question and answer competency review was developed by IDNS and ADNS and given randomly to staff to help measure the staffs' understanding of the information. The IDNS and ADNS utilized a current employee roster for tracking the in-services and exam completion. Those educated via telephone were questioned verbally and those educated in-person completed a written exam given by the IDNS/ADNS/Unit Manager/Weekend Supervisor. 18. On [DATE], the Administrator began daily audits to confirm that the residents who were out on appointments returned safely and timely. 19. A QA Committee Meeting (Administrator, IDNS, Medical Director via phone, MDS Director, Respiratory Therapy, Activities director, Assistant Social Services, Admissions, Social Services Director, Unit Manager, Therapy Director, Scheduler, ADNS, and Regional Nurse) was held on [DATE], to review the audits related to the resident determination process to validate residents' need for escort. The QA Committee reviewed the list of residents who could independently transport safely in the appointment books as a reference for nurses until a process could be developed and education could be completed on the process. The Administrator reported the results of her audit on whether the transported residents had returned safely to the facility to the QA Committee. 20. Beginning [DATE], audits of documentation were completed by the Unit Manager/ADNS/Social Services on documentation of residents leaving the facility to ensure proper signing in and out, with an audit plan of two (2) times a week for eight (8) weeks then two (2) times a month times one (1) month, then a minimum of quarterly. 21. The QA Committee will meet weekly times eight (8) weeks then two (2) times a month times one (1) month and then a minimum of quarterly. The SSA validated the facility implemented the following actions: 1. Interview with the SSD, on [DATE] at 1:35 PM, revealed Registered Nurse (RN) #3 informed her on [DATE], Resident #1 was missing after receiving a call from the resident's girlfriend. The SSD stated Resident #1 had not returned to the facility and his/her whereabouts were not known, at which point she attempted to locate the resident. She stated she made calls to local hospitals and notified the Administrator, the IDNS, and the police. Interview with the Police Detective, on [DATE] at 12:40 PM, revealed the SSD called him on [DATE] at 11:27 PM, and reported Resident #1 had gone to a medical appointment and had not returned to the facility. Interview with the IDNS, on [DATE] at 2:15 PM, revealed the SSD was notified Resident #1 was missing and made calls in an attempt to locate the resident, including calling the Police and hospitals. Interview with the Administrator, on [DATE] at 10:24 AM, revealed the SSD notified her on [DATE] that Resident #1 had not returned to the facility. Review of a Missing Person Report, dated [DATE] at 11:30 PM, revealed the facility notified the police Resident #1 never returned from a physician's appointment. 2. Interview with Resident #1's Responsible Party, on [DATE] at 10:00 AM, revealed he stated he was notified Resident #1 was missing. 3. Interview with the Maintenance Director, on [DATE] at 9:32 AM, revealed on [DATE] at 8:00 AM, he searched for the whereabouts of Resident #1 including inquiring at the physician's office where the resident was last seen and multiple locations where the resident might have gone. The Maintenance Director stated several staff looked for the resident, including the Admissions Director, the Activities Director, the Social Services Assistant, and others. He stated staff communicated with each other by cellular telephone texting and the search continued throughout the weekend. He stated the resident's girlfriend went with him to search multiple places throughout the city including under bridges. Interview with the Activities Director (AD), on [DATE] at 1:14 PM, revealed he received a call at home on [DATE] around 10:30 PM, from the Administrator informing him Resident #1 had not returned to the facility. The AD stated he went with another staff member to search for the resident, including at a Mission serving homeless people, and other places homeless people visited. Interview with the Assistant Director of Nursing Services (ADNS), on [DATE] at 10:45 AM, revealed she coordinated the search for Resident #1. She stated several staff members were directed to search in various locations of the city where they thought the resident might frequent, such as Missions, last known address, and homeless hangouts. Interview with the IDNS, on [DATE] at 2:15 PM, and the Administrator, on [DATE] at 10:24 AM, revealed facility staff worked with the Police while searching for Resident #1 in the community, including at a Mission serving homeless people, through the night and weekend until notified on [DATE], the resident was deceased . 4. Interview with the Regional Consultant, on [DATE] at 12:02 PM, revealed the facility worked with her by telephone conference on [DATE]. She directed the IDNS and ADNS to hold a QA meeting, discuss problems including transportation problems, update policies, and educate staff. Interview with the Maintenance Director, on [DATE] at 9:22 AM, revealed he attended the QA committee meeting on [DATE]. Interview with the AD, on [DATE] at 1:14 PM, revealed he attended the QA committee meeting on [DATE]. Interview with the IDNS, on [DATE] at 2:15 PM, and the ADNS, on [DATE] at 10:00 AM, revealed they attended the QA Committee meeting on [DATE], and discussed the event set forth in the notice of Immediate Jeopardy and developed a plan of action. Interview with the Medical Director, on [DATE] at 3:28 PM, revealed he attended the QA Committee meeting on [DATE], and discussed the action plan regarding Resident #1. Interview with the UM, on [DATE] at 2:43 PM, the Weekend Supervisor/Charge Nurse, on [DATE] at 10:25 AM, and the SSD, on [DATE] at 11:40 AM, revealed they would be responsible for making calls to the responsible party to determine if they could escort the resident to the appointment. If not able to escort, the responsible party could send a designee of his/her choice. The information would be documented in the appointment binder. Continued interview with the SSD, on [DATE] at 11:40 AM, revealed she would make subsequent calls to the responsible party/designee to let them know what time to be at the facility for the appointment. Social Services would arrange for an escort. If the responsible party would be escorting, Social Services would educate them regarding the process and if not willing to follow the process, an escort would be arranged. Interview with Administrator, on [DATE] at 3:45 PM, and the SSD, on [DATE] at 11:40 AM, revealed they attended the [DATE] QA Committee meeting and discussed the incident with Resident #1 and developed an action plan. Review of the QA Committee Meeting sign-in sheet, dated [DATE], revealed the IDNS, Administrator, AD, Maintenance Director, Medical Director, and several other staff met to discuss/review action plans. Review of the Transportation Policy, revised [DATE], revealed the policy revisions included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. 5. Interview with the SSD, on [DATE] at 11:40 AM, revealed she and the Social Services Assistant reviewed resident BIMS scores and completed updates to resident assessments on [DATE] and [DATE]. Interview with the Social Services Assistant, on [DATE] at 10:15 AM, revealed she and the SSD reviewed BIMS scores on [DATE] and [DATE], and completed updates. Review of facility documentation, dated [DATE] and [DATE], revealed eighty-eight (88) of eighty-eight (88) residents BIMS were audited to validate they were up to date. 6. Interview with the IDNS, on [DATE] at 2:15 PM, the ADNS, on [DATE] at 10:00 AM, and the SSD, on [DATE] at 1:55 PM, revealed on [DATE], they reviewed the appointment book for [DATE] through [DATE], to validate residents that had transportation needs had escorts. 7. Interview with the IDNS, on [DATE] at 2:15 PM, the ADNS, on [DATE] at 10:00 AM, and the SSD, on [DATE] at 1:55 PM, revealed during the Interdisciplinary Team (IDT) meeting on [DATE], they reviewed eight-nine (89) of eighty-nine (89) residents using their BIMS, diagnosis, and IDT knowledge of physical needs, to determine who could transport to non-emergent physician appointments without an escort. Review of the transportation binders, on [DATE] at 2:43 PM, revealed the binders contained a reference list of residents who could transport to appointments without an escort until a process could be developed and education completed. Interview with LPN #4, on [DATE] at 3:40 PM, and LPN #2, on [DATE] at 11:55 AM, revealed they were made aware of the list in the appointment book to utilize as a guide. Interview with Administrator, on [DATE] at 3:45 PM, revealed a reference list for nurses of residents who could go to appointments unescorted was placed in the appointment binders on the units. 8. Interview with LPN #2, on [DATE] at 2:38 PM, and LPN #3, on [DATE] at 3:32 PM, revealed they were to ensure a copy of the Transportation Form was sent with the resident when they went out to an appointment. Interview with the Weekend Supervisor, on [DATE] at 10:25 AM, and the UM, on [DATE] at 8:15 AM, revealed the Transportation Form would be filled out and sent along with the medical data when the resident was transported to an appointment. They both stated they trained the nursing staff to ensure the form went with the residents. Interview with the SSD, on [DATE] at 11:40 AM, and LPN #4, on [DATE] at 3:40 PM, revealed the facility developed a Transportation Form on [DATE], for them to fill out when residents were scheduled appointments. The form would be placed in the appointment binder so a copy would go with the resident at time of the appointment. Review of the Transportation Binders on [DATE], revealed copies of Transportation Forms were present. 9. Review of Resident #6 and #8 Release of Responsibility during Leave of Absence Sheet, undated, on [DATE], revealed residents' responsible parties were to sign the resident in and out on the sheet when going out for appointments. Interview with CNA #3, on [DATE] at 11:25 AM, revealed she must sign a resident in and out when escorting to an appointment, take a packet of information with her when she escorted a resident to an appointment, and give the packet to the physician. Interview with LPN #3, on [DATE] at 3:32 PM, revealed they were to ensure a copy of the Transportation Form was sent with the resident when they went out to an appointment. Interview with LPN #2, on [DATE] at 11:48 AM, revealed she was trained to print and send the residents face sheet/transfer sheet, a blank physician's progress note, Medication Administration Record [REDACTED]. Interview with the UM, on [DATE] at 2:43 PM, the Weekend Supervisor/Charge Nurse, on [DATE] at 10:25 AM, and the SSD, on [DATE] at 11:40 AM, revealed they would document the conveyance of the packet in the medical record. If the packet was not sent with the escort, they would immediately contact the physician's office and send the packet electronically. 10. Observation of the IDT morning meeting, on [DATE] at 9:10 AM, and [DATE] at 9:26 AM, revealed the team reviewed the appointment binders and transportation forms for completeness and accuracy. Resident escort needs for appointments were discussed. The team used resident BIMS, orientation, diagnosis, and physical limitations to make decisions. Interview with the SSD, on [DATE] at 11:40 AM, revealed she was responsible for reporting any abnormalities related the appointment binders and transportation forms to the QA committee meeting. She stated there were no abnormalities to report. Review of the IDT morning meeting documents revealed the IDT began the process of reviewing transportation forms and discussing residents escort needs on [DATE]. 11. Observation of the IDT Stand Down meeting, on [DATE] at 4:05 PM, revealed the Head Count protocol was implemented and discussed to ensure residents out on appointments were accounted for and follow-up was assigned. Interview with the Administrator, on [DATE] at 3:44 PM, revealed she conducted the Head Count Protocol at the stand down meeting each afternoo(TRUNCATED)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to provide the necessary care and supervision to residents assessed with [REDACTED].#1. On [DATE], at approximately 3:00 PM, Resident #1, whom the facility assessed with [REDACTED]. arranged by the facility. Interview with facility staff revealed the resident's girlfriend was meeting the resident at the physician's office. However, interview with the taxi driver revealed no one was there to meet the resident and the driver escorted Resident #1 into the physician's office and left the resident in the check-in line. Interview with Resident #1's girlfriend revealed she called the facility at 5:00 PM and informed staff her car broke down and she was unable to meet the resident at the physician's office and asked if the resident was back in the facility. Interviews revealed staff identified the resident had not returned; however, failed to call the physician's office to check on the resident. Staff was not aware the resident had never returned to the facility until approximately 9:00 PM, when Resident #1's girlfriend called the facility again wanting to speak with the resident and the resident could not be located. Video surveillance at the physician's office recorded Resident #1 leaving in a wheelchair at approximately 5:41 PM. Resident #1 was found by the local Police deceased next to a tree line near a set of railroad tracks on [DATE] at 4:00 PM, approximately nine (9) miles from the physician's office. Per the Police Detective interview, the preliminary cause of death was the resident's health condition and the elements. Review of the weather history for [DATE], revealed a high of seventy-three point nine (73.9) degrees Fahrenheit (F) and a low of fifty-five (55) degrees F. On [DATE], the low was fifty-five (55) degrees F with a high of sixty-four (64) degrees F by 4:00 PM. The facility's failure to have an effective system in place to provide the necessary care and supervision to residents while on an outing to a physician's office appointment has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency's (SSA) determined the facility completed corrective action prior to the initiation of the SSA's investigation on [DATE]; therefore, the Immediate Jeopardy was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy entitled Transportation, dated [DATE], revealed the facility would assist residents with arranging transportation to/from diagnostic appointments when necessary. Should it become necessary to transport a resident to a diagnostic service outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representation and inform them of the appointment. Should it become necessary for the facility to provide transportation, the Social Service Designee would be responsible for arranging the transportation through the business office. A member of the nursing staff, or social services, may accompany the resident to the appointment when the resident's family was not available if the resident was not alert or had significant personal needs. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have difficulty communicating words and finishing thoughts. The MDS stated the resident usually understood others but missed some part/intent of the message. The facility assessed the resident to need the extensive assistance of two (2) staff when transferring between surfaces, performing personal hygiene, and with toilet use and used a wheelchair for mobility. The resident was frequently incontinent of urine and always incontinent of bowel. The facility assessed Resident #1 with a Brief Interview for Mental Status score of four (4) out of fifteen (15) and determined the resident not interviewable. Review of Resident #1's Care Plan, dated [DATE], revealed the resident had impaired cognition and thought processes with interventions that directed staff to break tasks into one-step at a time increments, cue, reorient and supervise the resident as needed. In addition, staff was to communicate with the resident, family, and other caregivers regarding his/her capabilities and needs. Resident #1's Communication Care Plan, dated [DATE], revealed the resident had potential communication problems related to his/her impaired cognition with interventions that directed staff to encourage the resident to continue to state thoughts even if having difficulty, to focus on the word or phrase that made most sense, or respond to the feelings he/she was trying to express. Interventions also included to use communication techniques which enhanced interaction allowing adequate time for the resident to respond, do not rush the resident, and request clarification from the resident to ensuring he/she understood. Further review of Resident #1's Care Plan, dated [DATE], revealed the resident was incontinent and had a self-care performance deficit and interventions directed staff to assist the resident with bathing, personal hygiene, dressing, and oral care. Review of Resident #1's Nursing Documentation, dated [DATE], revealed Resident #1 had an appointment on [DATE]; however, the resident missed the appointment due to transportation issues. Nursing staff rescheduled the appointment for [DATE] at 3:00 PM. Interview with the Licensed Practical Nurse (LPN) #2, on [DATE] at 2:23 PM, revealed she had rescheduled Resident #1's appointment for [DATE] and made transportation arrangements with a taxi service. Interview with the Unit Manager (UM), on [DATE] at 8:15 AM, revealed Resident #1's Responsible Party lived out of town and the girlfriend lived in town. The UM stated she called the girlfriend the morning of [DATE], to confirm the appointment place and time. She stated the girlfriend informed her she would meet the resident at the physician's office; however, the UM did not arrange for Resident #1 to be supervised by staff during the ride to and from the physician's office or to stay with the resident in case the girlfriend did not meet the resident at the office. Interview with the Social Services Director (SSD), on [DATE] at 1:35 PM, revealed she was responsible for setting up transportation arrangements for residents when they had appointments and believed Resident #1 did not need special arrangements/supervision for physician office visits. The SSD did not make Resident #1's transportation arrangements and believed nursing staff had rescheduled the appointment for [DATE] and made transportation arrangements. She stated it was the facility practice to allow residents to travel via taxi/van, without staff escorts in order to meet family members at physician offices. However, per the facility's policy, staff may accompany the resident to the appointment when the resident's family was not available if the resident was not alert or had significant personal needs. Record review revealed the facility had assessed Resident #1 as cognitively impaired with communication deficits and required extensive assistance of two (2) staff for transfers and personal hygiene. Interview with Certified Nursing Assistant (CNA) #2, on [DATE] at 11:15 AM, revealed Resident #1 was confused, incontinent at times and wore incontinent briefs, and had a feeding tube. She stated the resident needed assistance of one (1) to two (2) with activities of daily living and needed supervision for safety because the resident was at risk for falls. The CNA revealed the resident had trouble communicating due to a recent stroke and would get frustrated and cry when he/she could not get his/her words out. Per interview, she assisted Resident #1 with washing up and dressing for his/her physician appointment on [DATE]. The resident wore a pair of shorts, a T-Shirt, and flip-flops with non-skid socks to the appointment. CNA #2 stated after assisting the resident with activities of daily living, she pushed the resident to the front lobby and left him/her there to wait on the taxi. Interview with the Taxi Driver, on [DATE] at 4:10 PM, revealed he picked up Resident #1 at the facility and transported the resident to the physician's office on [DATE]. He stated the resident was in a wheelchair and when he got to the physician's office, he could tell the resident needed assistance. He stated he pushed the resident into the physician's office building and asked the receptionist if they could transport the resident to the office. The receptionist said they did not transport residents so he took the resident to the third floor and left the resident in line to sign-in at the counter. The Taxi Driver stated he gave the resident his card with the phone number to call him back for pick-up when the appointment was over. He stated later in the evening he remembered the resident did not call him back so he called the facility to inquire about the resident, but no one answered the phone at the facility. Further interview with the Unit Manager (UM), on [DATE] at 8:15 AM, revealed the Director of Rehabilitation (DOR) asked her, in passing, if Resident #1 had returned to the facility and she responded the resident was still at the appointment. The UM stated she left for the day and did not give any further thought to Resident #1 until contacted around 2:00 AM on [DATE], regarding Resident #1's disappearance. She stated when she came back to the facility; she learned the Interim Director of Nursing Services had a phone conversation with the girlfriend earlier in the day on [DATE], letting her know she was not able to make it to the physician's appointment. She stated someone in the facility should have followed-up with the physician's office after determining the girlfriend did not show for the appointment. The UM stated if someone had followed-up after the girlfriend's notification, the facility could have ensured the resident was provided the necessary care and services to return to the facility safely. Interview with Resident #1's Girlfriend, [DATE] at 11:05 AM, revealed she called the facility at 5:00 PM and informed staff her car broke down and she was unable to meet the resident at the physician's office and asked if the resident was back in the facility. She called the facility around 9:00 PM to speak to Resident #1 and again informed staff she did not attend Resident #1's physician's appointment due to car trouble. She stated staff informed her the resident was not back from the appointment yet. She stated she got upset and went to look for the resident at the physician's office. Interview with the Interim Director of Nursing Services (IDNS), on [DATE] at 2:15 PM, revealed she received a call around 5:00 PM on [DATE], from Resident #1's girlfriend wanting to know if the resident had made it back to the facility. The IDNS stated the girlfriend informed her she had car trouble and did not make it to Resident #1's appointment. The IDNS stated the DOR came into her office and offered to go check to see if the resident had returned. The IDNS stated after the DOR left the office, she had no further involvement with the girlfriend or the resident's care. The IDNS stated she never thought anything was amiss regarding the resident until staff contacted her around 10:45 PM, informing her Resident #1 had not returned from his/her physician appointment. The IDNS stated after Resident #1 went missing, she reviewed his/her medical record and determined the resident had severe cognitive impairment due to a stroke, history of respiratory failure requiring a breathing machine, had a feeding tube in place, and required a wheelchair for mobility. She stated the facility believed residents could be transported safely in a taxi to and from appointments alone, with a family member meeting the resident at the office; however, the facility's policy stated a member of the nursing staff, or social services, may accompany the resident to the appointment when the resident's family was not available if the resident was not alert or had significant personal needs. Interview with the Taxi Service Manager, on [DATE] at 2:30 PM, revealed the taxi service picked-up residents at the facility and dropped them off at the door at the scheduled location. The Manager stated the driver had no way of knowing the needs of the resident he/she was transporting. She stated it was the responsibility of the facility to send an escort with the resident to ensure resident needs were met. The Manager stated there were times drivers would assist residents in wheelchairs into buildings; however, if they had other passengers in the taxi they had to remain with the vehicle. The Manager stated the driver would give the resident or the escort a card with a return number to call for transportation pick-up after the appointment. The Manager stated the driver would have no way of knowing if a resident was capable of making the return phone call or not. Review of Resident #1's Gastroenterology Consult documentation, dated [DATE] and timed 5:00 PM, revealed the Physician Assistant (PA) noted the resident was not very aware of his/her medical condition. The PA noted it was unclear if Resident #1's slurred speech and forgetfulness was due to the brain bleed or to Hepatic [DIAGNOSES REDACTED]. The consult noted it was difficult to assess the resident as he/she was a poor historian and no family was with him/her at the appointment. Interview with the Administrator, on [DATE] at 10:24 AM, revealed the facility sent Resident #1 to a physician's office via a taxi on [DATE], with the understanding the girlfriend would meet the resident at the office; however, the girlfriend had car trouble and never made it to the appointment. She stated the girlfriend informed the facility she was not able to attend the appointment due to car trouble. The Administrator stated the facility determined through video surveillance footage Resident #1 exited the physician's office building at 5:41 PM, after being assessed. The Administrator stated the facility did not follow-up with the resident or the physician's office after the girlfriend made them aware she did not attend the appointment. However, she believed the resident made a conscious decision to leave the physician's office without asking for assistance to return to the facility. The Administrator stated the facility searched for the resident until notified via the coroner on [DATE], that the resident was found deceased on [DATE]. Interview with the Police Detective, on [DATE] at 12:40 PM, revealed Resident #1 was found deceased on e and half (1.5) days after exiting the physician's office, nine point one (9.1) miles away from the office, on [DATE] at 4:00 PM. The Police Detective stated the resident's wheelchair was found near a railroad track and his/her body close by near a tree line. The Police Detective stated the preliminary cause of death was the resident's health condition and the elements. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Social Services Director began to call the area hospitals, and notified the Administrator, Interim Director of Nursing Services (IDNS), and police, and a missing person report was filed. 2. The Responsible Party (RP) was notified on [DATE]. 3. On [DATE], staff began searching the areas of the clinic to include missions, under bridges, bars, and parking structures. The Administrator and IDNS worked throughout the night heading up the search, communicating with police and regional staff. The search continued throughout the weekend until Monday, [DATE], when the IDNS was notified by the coroner that Resident #1 was found deceased . 4. On [DATE], the facility worked with the Regional Consultant to develop an immediate plan to address the occurrence and on [DATE], the QA Committee (consisting of the Administrator, IDNS, ADNS, Unit Manager, SSD, Activities Director, and Medical Director) met and reviewed the action plan that included revision of the Transportation Policy for diagnostic appointments (non-emergent, non-dialysis scheduled physician appointments) that included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. The Unit Manager/Charge Nurse/Social Services would call the resident's responsible party to determine if he/she could escort the resident to the appointment and document in the appointment binder by Unit Manager/Charge Nurse/Social Services, if not, the responsible party could send a designee of his/her choice, which confirmed the responsible party/designee was notified of the appointment. Social Services would subsequently call the responsible party/designee to let him/her know what time to be at the facility for the appointment (when the responsible party/designee was to escort). If the responsible party/designee could not attend the appointment, then Social Services did not call him/her. When the responsible party/designee is the escort, Social Services would educate the responsible party that he/she must ride with the resident to and from the appointment. If the responsible party/designee cannot to do this, then Social Services or the scheduler arranges for a staff escort. 5. On [DATE] and [DATE], the Social Services Team, consisting of the Social Services Director (SSD) and Social Services Assistant, reviewed eighty-eight (88) of eighty-eight (88) active residents to validate Brief Interview for Mental Status' (BIMS) were up-to-date and any needed updates were made. 6. On [DATE], the Interdisciplinary Team (IDT) (consisting of the IDNS, the Assistant Director of Nursing Services (ADNS), and the SSD) reviewed current appointments for the week of [DATE] thru [DATE]; to validate residents that had transportation needs met for escorts. 7. On [DATE], the IDT reviewed eighty-nine (89) of eighty-nine (89) active residents in the facility using BIMS, diagnosis, and IDT knowledge of physical needs to determine who could transport to non-emergent physician appointments without an escort. A list of residents who could transport safely was posted in the appointment books as a reference for nurses until a process could be developed and education completed. 8. A Transportation Form was developed on [DATE], and first used on [DATE]. The Unit Manager/Charge Nurse/Social Services fill out the Transportation Form for the appointment and place a copy in the appointment binder so the form can go with the resident to the appointment. 9. When transportation arrives at the facility to take a resident to an appointment and the escort is present, the resident will be signed out of the facility by the responsible party/designee/staff escort. The escort will be given a packet with the Transportation Form and information relating to the resident's care needs to give to the physician's office. The Charge Nurse /Unit Manager/Social Services will document the conveyance of the packet in the medical record. If the packet is not sent with the escort, the Charge Nurse/Unit Manager/ Social Services will immediately contact the physician's office and send the packet electronically. 10. Beginning [DATE], Monday-Friday at the morning stand-up meeting, the IDT began reviewing the process for the appointment binders and Transportation Forms for accuracy and completeness. Residents going to appointments will be discussed to validate the escort needs of the residents. Tools used to aid this discussion included BIMS score, orientation of residents, diagnosis, and physical limitations of the resident. Beginning [DATE], Social Services reported any abnormalities to the QA Committee. 11. Beginning [DATE], the head count protocol for the afternoon Monday-Friday stand down meeting was implemented. At the afternoon stand-down meeting, a head count will be completed by the IDT to confirm that all residents having gone out for appointments have returned. Each resident's return status will be discussed at the meeting. If a resident has not returned from an appointment, the Administrator/designated representative will assign an IDT member to complete follow-up on that resident. That person will report the resident's status to the Administrator/designated representative after speaking with the escort. 12. Beginning [DATE], Monday-Friday at morning meeting and as needed, the IDT reviewed physician's orders [REDACTED]. On the weekends, the nursing supervisor reviewed physician's orders [REDACTED]. On Mondays, the IDT reviews the weekend nurses' interventions and updates the care plans as necessary. 13. On [DATE], the Regional Consultant educated the IDNS, and the IDNS then educated the ADNS, Unit Managers, and Weekend Supervisor, and by [DATE], all active nurses, twenty-three (23) of twenty-three (23), were educated by the IDNS, ADNS, Unit Manager or Weekend Supervisor, to follow-up at the end of a four (4) hour window from the scheduled appointment time to check on the location of the resident and if the resident had not returned to the facility, the nurse was to notify the Unit Manager/Charge Nurse. If a resident had not returned to the facility within four (4) hours of the scheduled appointment time, the Unit Manager/Charge Nurse would then follow-up with the escort or the physician's office to check on the resident's status. The Unit Manager/Charge Nurse would document the follow-up in a nursing note. 14. The ADNS and Unit Manager had a Train the Trainer course (on the action plan) by the IDNS on [DATE], and Weekend Supervisor had a Train the Trainer on [DATE]. 15. Beginning [DATE] and completed on [DATE], education was provided to sixty-two (62) of sixty-two (62) staff including active nurses, certified medication aids, resident care associates, and certified nursing assistants, and department leaders. Staff who were on a leave of absence and/or prn would be educated prior to returning to work in the facility. Agency Staff would be educated prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during orientation period by the IDNS/ADNS/Unit Manager/Nursing Supervisor or Regional Nurse before assuming an assignment. The in-service education included the following: making nursing staff aware of the resident list in the appointment book to utilize as a guide; filling out the transportation form and sending it along with the medical data when the resident was transported to an appointment; nurses documenting out-of-facility appointments to include leaving and returning documentation; requirement of residents/responsible party/designee to sign in and out; providing medical information to caregivers as per care plan; process for scheduling appointment, which included transportation, escort use, and notification of responsible party/designee; to follow-up on residents who were out of the facility for four (4) or more hours; and the stand-down head count and follow-up. 16. On [DATE], the Regional Director of Clinical Operations educated the MDS Nurse regarding reviewing and updating care plans with goals and appropriate interventions related to resident [DIAGNOSES REDACTED]. 17. A question and answer competency review was developed by IDNS and ADNS and given randomly to staff to help measure the staffs' understanding of the information. The IDNS and ADNS utilized a current employee roster for tracking the in-services and exam completion. Those educated via telephone were questioned verbally and those educated in-person completed a written exam given by the IDNS/ADNS/Unit Manager/Weekend Supervisor. 18. On [DATE], the Administrator began daily audits to confirm that the residents who were out on appointments returned safely and timely. 19. A QA Committee Meeting (Administrator, IDNS, Medical Director via phone, MDS Director, Respiratory Therapy, Activities director, Assistant Social Services, Admissions, Social Services Director, Unit Manager, Therapy Director, Scheduler, ADNS, and Regional Nurse) was held on [DATE], to review the audits related to the resident determination process to validate residents' need for escort. The QA Committee reviewed the list of residents who could independently transport safely in the appointment books as a reference for nurses until a process could be developed and education could be completed on the process. The Administrator reported the results of her audit on whether the transported residents had returned safely to the facility to the QA Committee. 20. Beginning [DATE], audits of documentation were completed by the Unit Manager/ADNS/Social Services on documentation of residents leaving the facility to ensure proper signing in and out, with an audit plan of two (2) times a week for eight (8) weeks then two (2) times a month times one (1) month, then a minimum of quarterly. 21. The QA Committee will meet weekly times eight (8) weeks then two (2) times a month times one (1) month and then a minimum of quarterly. The SSA validated the facility implemented the following actions: 1. Interview with the SSD, on [DATE] at 1:35 PM, revealed Registered Nurse (RN) #3 informed her on [DATE], Resident #1 was missing after receiving a call from the resident's girlfriend. The SSD stated Resident #1 had not returned to the facility and his/her whereabouts were not known, at which point she attempted to locate the resident. She stated she made calls to local hospitals and notified the Administrator, the IDNS, and the police. Interview with the Police Detective, on [DATE] at 12:40 PM, revealed the SSD called him on [DATE] at 11:27 PM, and reported Resident #1 had gone to a medical appointment and had not returned to the facility. Interview with the IDNS, on [DATE] at 2:15 PM, revealed the SSD was notified Resident #1 was missing and made calls in an attempt to locate the resident, including calling the Police and hospitals. Interview with the Administrator, on [DATE] at 10:24 AM, revealed the SSD notified her on [DATE] that Resident #1 had not returned to the facility. Review of a Missing Person Report, dated [DATE] at 11:30 PM, revealed the facility notified the police Resident #1 never returned from a physician's appointment. 2. Interview with Resident #1's Responsible Party, on [DATE] at 10:00 AM, revealed he stated he was notified Resident #1 was missing. 3. Interview with the Maintenance Director, on [DATE] at 9:32 AM, revealed on [DATE] at 8:00 AM, he searched for the whereabouts of Resident #1 including inquiring at the physician's office where the resident was last seen and multiple locations where the resident might have gone. The Maintenance Director stated several staff looked for the resident, including the Admissions Director, the Activities Director, the Social Services Assistant, and others. He stated staff communicated with each other by cellular telephone texting and the search continued throughout the weekend. He stated the resident's girlfriend went with him to search multiple places throughout the city including under bridges. Interview with the Activities Director (AD), on [DATE] at 1:14 PM, revealed he received a call at home on [DATE] around 10:30 PM, from the Administrator informing him Resident #1 had not returned to the facility. The AD stated he went with another staff member to search for the resident, including at a Mission serving homeless people, and other places homeless people visited. Interview with the Assistant Director of Nursing Services (ADNS), on [DATE] at 10:45 AM, revealed she coordinated the search for Resident #1. She stated several staff members were directed to search in various locations of the city where they thought the resident might frequent, such as Missions, last known address, and homeless hangouts. Interview with the IDNS, on [DATE] at 2:15 PM, and the Administrator, on [DATE] at 10:24 AM, revealed facility staff worked with the Police while searching for Resident #1 in the community, including at a Mission serving homeless people, through the night and weekend until notified on [DATE], the resident was deceased . 4. Interview with the Regional Consultant, on [DATE] at 12:02 PM, revealed the facility worked with her by telephone conference on [DATE]. She directed the IDNS and ADNS to hold a QA meeting, discuss problems including transportation problems, update policies, and educate staff. Interview with the Maintenance Director, on [DATE] at 9:22 AM, revealed he attended the QA committee meeting on [DATE]. Interview with the AD, on [DATE] at 1:14 PM, revealed he attended the QA committee meeting on [DATE]. Interview with the IDNS, on [DATE] at 2:15 PM, and the ADNS, on [DATE] at 10:00 AM, revealed they attended the QA Committee meeting on [DATE], and discussed the event set forth in the notice of Immediate Jeopardy and developed a plan of action. Interview with the Medical Director, on [DATE] at 3:28 PM, revealed he attended the QA Committee meeting on [DATE], and discussed the action plan regarding Resident #1. Interview with the UM, on [DATE] at 2:43 PM, the Weekend Supervisor/Charge Nurse, on [DATE] at 10:25 AM, and the SSD, on [DATE] at 11:40 AM, revealed they would be responsible for making calls to the responsible party to determine if they could escort the resident to the appointment. If not able to escort, the responsible party could send a designee of his/her choice. The information would be documented in the appointment binder. Continued interview with the SSD, on [DATE] at 11:40 AM, revealed she would make subsequent calls to the responsible party/designee to let them know what time to be at the facility for the appointment. Social Services would arrange for an escort. If the responsible party would be escorting, Social Services would educate them regarding the process and if not willing to follow the process, an escort would be arranged. Interview with Administrator, on [DATE] at 3:45 PM, and the SSD, on [DATE] at 11:40 AM, revealed they attended the [DATE] QA Committee meeting and discussed the incident with Resident #1 and developed an action plan. Review of the QA Committee Meeting sign-in sheet, dated [DATE], revealed the IDNS, Administrator, AD, Maintenance Director, Medical Director, and several other staff met to discuss/review action plans. Review of the Transportation Policy, revised [DATE], revealed the policy revisions included addressing when an escort would be provided and the expectations of the responsible party or designee when escorting a resident to an appointment. 5. Interview with the SSD, on [DATE] at 11:40 AM, revealed she and the Social Services Assistant reviewed resident BIMS scores and completed updates to resident assessments on [DATE] and [DATE]. Interview with the Soc(TRUNCATED)