Every finding on record at Community Place

Based on observations, interviews, and facility policy reviews, the facility failed to properly store frozen foods in the freeze for one (1) of four (4) survey days, as evidenced by, unsealed bags in the freezer. This has the potential to affect all residents in the facility. Findings Include:Record review of the facility's policy Storage of Frozen Food with a review date of 11/23 revealed The facility ensures the quality and safety of frozen food through accepted storage practices .8. Opened boxes with liners should be closed and sealed tightly with packing tape or twists ties .On 05/18/2026 at 10:15 AM, during the initial tour of the kitchen with the Dietary Manager (DM), nine (9) food items in the freezer were found to not be properly stored. The following items were observed: 1. Red [NAME] sausage in a plastic bag - bag was not sealed. 2. [NAME] dinner rolls in a brown box - plastic liner was torn open. 3. Rid's cobbler crust in a box - plastic bag torn open. 4. Bake Craft bread sticks, 10-pound box - plastic bag torn open. 5. [NAME] sausage - liner bag torn open. 6. Lima beans, 30-pound box - plastic liner torn open. 7. [NAME] Spunkmeyer frozen sugar cookies in box - plastic liner bag torn open. 8. [NAME] Spunkmeyer frozen chocolate chip cookies - plastic liner bag torn open. 9. [NAME] Dean sausage links, 10-pound box - plastic liner bag torn open.On 05/18/2026 at 10:37 AM, during an interview the DM confirmed that all bags in the freezer and cooler should be sealed, as this prevents freezer burn. She further stated that the cook is responsible for ensuring food is sealed in the freezer and cooler, and that improperly stored food could spoil and make residents sick.On 05/21/2026 at 8:40 AM, an interview with the Nursing Home Administrator (NHA) confirmed that dietary staff should have closed the bags, as doing so keeps food fresh and prevents spoilage. He stated his expectation is that dietary staff follow all rules and regulations for serving safe food and not serving contaminated food to residents.

Based on record review, interview, and facility policy review, the facility failed to ensure advance directives were completed and readily available on the charts for seven (7) of twenty-three (23) residents reviewed for advance directives. (Residents #1, 28, 29, 30, 31, 34, and 43) Findings included: A review of the facility policy titled Advance Directives, undated, revealed, Policy Statement: Advance directives will be represented in accordance with state law and facility policy. Policy Interpretation and Implementation . 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . A record review of the medical records for Residents #1, 28, 29, 30, 31, 34, and 43 revealed there was no documentation regarding information as to whether or not the resident had executed an advance directive. A record review of the Admission Record revealed the facility admitted Resident #1 on 01/15/1996 with diagnoses including Hemiplegia and Hemiparesis, Resident #28 on 07/09/2019 with diagnoses including Parkinson's Disease, Resident #29 on 11/21/2014 with diagnoses including Hemiplegia and Hemiparesis, Resident #30 on 03/23/2015 with diagnoses including Hemiplegia, Resident #31 on 05/14/2015 with diagnoses including Hypertension, Resident #34 on 01/06/2016 with diagnoses including Hemiplegia and Hemiparesis, and Resident #43 on 09/03/2021 with diagnoses including Hypertension. On 01/15/2025 at 12:15 PM, during an interview, the Admissions Director revealed that many of the residents who had been in the facility for a significant amount of time did not have written documentation of their decision to formulate or not formulate an advance directive readily available in their charts. She stated that this documentation was likely in their admission files, which were currently stored in the facility's storage area. On 01/15/2025 at 4:23 PM, during an interview, the Administrator confirmed that advance directives were not readily available in residents' charts. He stated this might be a training issue regarding the execution of all aspects of the advance directive requirements.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident's right to a dignified existence related to a urinary catheter drainage bag that did not have a privacy covering for one (1) of three (3) residents reviewed for catheters. (Resident #16) Findings included: A review of the facility's policy, Resident Rights, undated, revealed, .Policy Interpretation and Implementation .1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a. a dignified existence . On 01/14/2025 at 8:12 AM, during an observation, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door, with no privacy cover. The urine in the drainage bag was visible from the open door. On 01/14/2025 at 12:31 PM, during an observation, Resident #16 remained in bed. The urinary drainage bag remained uncovered with yellow urine visible. There was no privacy covering for the drainage bag. On 01/14/2025 at 12:32 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated he was responsible for Resident #16's care. He explained that a collection bag cover ensures others cannot see the contents of the bag, maintaining the resident's dignity. CNA #1 confirmed the resident did not have a privacy covering on the drainage bag and he immediately retrieved one for the resident. On 01/14/2025 at 2:14 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed that Resident #16's urinary drainage bag lacked a privacy cover. She stated the catheter bag should always have a privacy cover, per facility policy, to ensure dignity and prevent the collection bag and tubing from contacting the floor. On 01/16/2025 at 1:27 PM, during an interview, the Assistant Director of Nursing (ADON) stated his expectation was that all nursing staff ensure urinary catheters are managed per facility policy. He emphasized that catheter bags should always have privacy covers to maintain dignity. A record review of the Admission Record revealed the facility admitted Resident #16 on 11/04/2024 with diagnoses including Pressure Ulcer of Sacral Region, Unspecified Stage. A record review of the Order Summary Report with active orders as of 1/16/2025 revealed a physician's order, dated 09/03/2024, to change the suprapubic (indwelling) catheter on the third (3rd) of each month and as needed. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2024 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review the facility failed to accommodate the needs and preferences of residents who required adaptive equipment to take a shower for (1) of (23) sampled residents. Resident #1. Findings Include: A review of the facility policy, Resident Rights,, undated, revealed, Policy Statement .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .h. be supported by the facility in exercising his or her rights . On 1/14/25 at 10:38 AM, during an interview with Resident #1, he revealed that he would like to take a shower from time to time. He indicated that he was told there is no shower chair available for him, so he has to rely on bed baths. On 1/15/25 at 9:41 AM, Certified Nursing Assistant #2 (CNA) explained that he has cared for the resident over the past six months. He explains that the facility does not have a shower chair to accommodate his request for a shower but does provide the resident with a bed bath daily. On 1/16/25 at 10:45 AM, in a phone interview with the mother and Resident Representative (RR), she revealed that a couple of months ago she shared her concern about her son, Resident #1, wanting a shower with the Director of Nursing (DON) and the Administrator. She explained that she was told they would look into getting a bariatric shower chair for him, like the one he had at their old building. On 1/16/25 at 11:20 AM, in an interview, the Director of Rehabilitation recalled that Resident #1 was evaluated, and it was concluded that, due to his poor upper trunk control, taking showers would not be safe. He mentions that there may be a special chair available for him somewhere with an outside supplier, but he does not know of one. On 1/16/2025 at 11:37 AM, in an interview with the Administrator, he explained that at the facility's previous building, Resident #1 had a chair he could use for showering. However, it was old, and the decision was made not to bring it to the new building during the move. The Administrator confirmed that Resident #1 should be able to shower whenever he wishes and have the necessary equipment to do so. On 1/16/2025 at 12:01 PM, during an observation and follow-up interview with the Director of Rehabilitation, the facility's current shower chair was inspected. The Director of Rehabilitation indicated that it could be possible, with further evaluation and additional staff assistance, for Resident #1 to use the current shower chair. A review of the Admission Record reveals the facility admitted Resident #1 on 1/15/1996 with diagnosis including Hemiplegia and Hemiparesis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/24 revealed Resident #1 had a Brief Interview Mental Score (BIMS) of 15, indicating the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a resident was free from a physical restraint imposed for staff convenience related to fall prevention for one (1) of 23 sampled residents. Resident #52. Findings included: A review of the facility's policy titled Use of Restraints, revised April 2017, revealed, .Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or the prevention of falls . On 01/14/25 at 09:05 AM, during an observation, Resident # 52 was sitting in a wheelchair with a lap table secured to the wheelchair. On 01/14/25 at 12:23 PM, during an observation of the lunch meal in the dining room, Resident #52 did not have the lap tray attached to her wheelchair. Her posture was stable, and she was not leaning during the meal. A Certified Nurse Aide (CNA) attached a lap tray to Resident #52's chair before she was transported out of the room. On 01/16/2025 at 3:11 PM, during an interview, CNA #3 who is the Lead CNA, stated the lap tray was used to prevent Resident #52 from falling. She explained that when the resident became agitated, she would beat on the lap tray and yell for help. She stated the lap tray was removed every 15 minutes and when the resident needed toileting. She also noted that most falls occurred on the 3:00 PM to 11:00 PM shift when it was hard to monitor the resident. She added that CNAs did not document lap tray removal every 15 minutes, as it was the nurse's responsibility. On 01/16/2025 at 3:30 PM, during an interview, CNA #4, who cared for Resident #52 on the 3:00 PM to 11:00 PM shift, stated she only released the lap tray when the resident needed to use the bathroom. She reported the resident had the lap tray on pretty much all the time during her shift. CNA #4 was unaware of the reason for the lap tray but noted she had been told the resident had a history of falls. On 01/16/2025 at 3:35 PM, during an interview, Licensed Practical Nurse (LPN) #3 stated that before the lap tray was implemented, Resident #52 had required one-on-one (1:1) supervision. She explained that the lap tray was used to prevent the resident from falling and that CNAs were supposed to release it every two hours, as documented on the Electronic Medication Administration Record (EMAR). She also noted that the resident had fallen twice in recent months, including once with the lap tray in place. On 01/16/2025 at 3:45 PM, during an interview, the Assistant Director of Nursing (ADON) stated the lap tray was used for safety due to Resident #52's history of falls and attempts to get out of her chair. He acknowledged that the resident had fallen with the lap tray in place and that without the lap tray, the facility would be unable to prevent her from falling. A record review of the Admission Record revealed the facility admitted Resident #52 on 08/09/2022 and she had current diagnoses including Parkinson's Disease. A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #52 had a physician's order, dated 5/20/2024, for a lap tray when in wheelchair, during waking hours, release every two hours for repositioning and activities of daily living (ADL) care. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2024 revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of four (4), indicating severe cognitive impairment. A record review of Resident #52's Lap Tray Checklist, dated 12/18/2024 to 01/16/2025, revealed the lap tray was not documented as being removed every two hours per the physician order. A record review of Resident #52's Initial Assessment for Application of Restraint, dated 05/14/2024, revealed a history of over 20 falls with head contusions and unsafe attempts to ambulate. A record review of Resident #52's Physical Restraint Consent, dated 06/10/2024, indicated the use of the lap tray for safety. A record review of Resident #52's Restraints Physical Quarterly/Annual Evaluation, dated 11/18/2024, indicated the use of restraints was due to unsteady gait, agitated behavior, aggressive behavior, frequent falls, and attempts to self-transfer.

Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care to a diabetic resident requiring nail care by a Registered Nurse (RN) for one (1) of 23 residents whose nails were observed. Resident #31. Findings included: A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene . On 01/14/2025 at 8:29 AM, during an observation, Resident #31 was seated in his wheelchair in his room. His fingernails were noted to be long, dirty, and jagged. On 01/15/2025 at 12:21 PM, during an observation in the dining room, Resident #31 was seen eating lunch. His fingernails remained long, dirty, and jagged. On 01/16/2025 at 12:28 PM, during an interview, the Assistant Director of Nursing (ADON) stated that two Registered Nurses are responsible for providing diabetic nail care. He explained that residents' nails are supposed to be cleaned and cut weekly. On 01/16/2025 at 12:32 PM, during an interview and observation, the ADON examined Resident #31's fingernails. He confirmed that the nails on Resident #31's left hand were dirty and needed to be cleaned. He stated that one hand was clean while the other was not. The ADON acknowledged that nails should not be cut too short but expressed his expectation that nurses clean and cut residents' nails weekly. A record review of the Admission Record revealed the facility admitted Resident #31 on 5/14/2015 and he had current diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia. A record review of Resident #31's Order summary Report with active orders as of 1/16/2025 revealed a physician's order, dated 12/4/24, for diabetic nail care to be provided by a Registered Nurse (RN) every Wednesday and as needed. A record review of Resident #31's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident was mildly cognitively impaired. Section GG was coded as dependent for personal hygiene. A record review of the January 2025 Electronic Treatment Administration Record (ETAR) revealed the RN staff did not document that diabetic nail care was provided on 01/01/2025 or 01/15/2025.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as evidenced by the catheter drainage bag coming into direct contact with the floor for one (1) of 1 resident reviewed with a catheter. Resident #16 Findings included: A review of the facility's policy, Catheter Care, Urinary, undated, revealed, .The purpose of this procedure I to prevent catheter-associated urinary tract infections .Infection Control .7 Be sure the catheter tubing and drainage bag are kept off the floor . During an observation on 01/14/2025 at 8:12 AM, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door. The drainage bag was touching the floor. During an observation on 01/14/2025 at 12:31 PM, Resident #16 remained in bed. The urinary drainage bag remained touching the floor in the room. During an interview on 01/14/2025 at 12:32 PM, Certified Nursing Assistant (CNA) #1 stated he was responsible for Resident #16's care. He explained that a drainage bag privacy cover prevents it from contacting the floor directly, reducing the risk of contamination. During an interview on 01/14/2025 at 2:14 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #16's urinary drainage bag should not be on touching the floor as per the facility's policy. During an interview on 01/16/2025 at 1:27 PM, the Assistant Director of Nursing (ADON) stated his expectation was that all nursing staff ensure urinary catheters are managed per facility policy. He emphasized that catheter drainage bags and tubing must be positioned to prevent contact with the floor. A record review of the Admission Record revealed the facility admitted Resident #16 on 11/04/2024 with diagnoses including Pressure Ulcer of Sacral Region, Unspecified Stage. A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #16 had a physician's order, dated 09/03/2024, to change the suprapubic (indwelling) catheter on the third (3rd) of each month and as needed. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2024 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interview and record review, the facility failed to prevent possible complications related to the storage of a Continuous Positive Airway Pressure (CPAP) mask, for one (1) of two (2) residents reviewed for respiratory. Resident #47 Findings included: On 1/14/2025 at 8:49 AM, during an interview, Resident #47 stated she uses her CPAP machine nightly. She explained that the mask had never been stored in a designated bag and was left on top of the dresser by her bedside. On 1/15/2025 at 12:08 PM, during an observation, Resident #47 was eating lunch in her room, and her CPAP mask remained on the table without being stored in a bag. On 1/15/2025 at 2:32 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed that the mask was not in a designated storage bag on 1/14/2025 or 1/15/2025. She stated the mask should be stored in a bag to prevent it from getting dirty and causing complications. On 1/15/2025 at 4:15 PM, during an interview, Registered Nurse (RN) #1, the Infection Preventionist, stated the mask should always be stored in a bag to prevent the resident from acquiring an infection. On 1/15/2025 at 4:18 PM, during an interview, the Assistant Director of Nursing (ADON) stated the CPAP mask should be stored in a bag when not in use. He explained the bag should be labeled with the date, and the mask should be cleaned weekly, placed in a clean bag after cleaning, and the bag replaced weekly to prevent infection. A record review of the Admission Record revealed the facility admitted Resident #47 on 2/28/2023 with diagnoses including Obstructive Sleep Apnea. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/2024 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Record review of the Order Summary Report with active orders as of 1/16/2025 revealed an order dated 1/15/2025 for CPAP Machine Mask to be placed in bag after each use daily.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and a medication cart were locked and secured for one (1) of three (3) medication carts observed. Findings included: A review of the facility's policy, Medication Labeling and Storage undated, revealed, .The facility stores all medications and biologicals in locked compartments . A review of the facility's policy, Administering Medications, undated, policy revealed, .Medications shall be administered in a safe and timely manner as prescribed. Policy Interpretation and Implementation .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide .No medications are to be kept on top of the cart. The cart must be clearly visible to personnel administering medications, and all outside surfaces must be inaccessible to residents or others passing by . On 01/14/2025 at 7:40 AM, during an observation, an unattended, unlocked medication cart was noted with an unlabeled white tablet in a medication cup left on top of the cart. The cart remained unattended for approximately three (3) minutes. On 01/14/2025 at 8:00 AM, during an interview, Licensed Practical Nurse (LPN) #1 stated that she had pulled a medication for a resident and then walked away from her medication cart to respond to another resident, leaving the cart unlocked and out of her sight. She confirmed this action was a safety issue and could lead to potential medication errors. On 01/16/2025 at 1:27 PM, during an interview, the Assistant Director of Nursing (ADON) stated his expectation during medication administration and storage was that no medications be left on top of carts without full nursing supervision. He also stated that all carts should be locked when not attended by licensed staff. The ADON noted that a resident could access the cart or medications.

Based on staff interview and the Facility Assessment review, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning that do not require activation of the facility's emergency plan for three (3) of (3) days of survey. Findings Included: A record review of the facility's Facility Hierarchy (Facility Assessment), signed 7/1/2024, revealed the Plan for average daily schedule of direct care staff to meets in 24-hour period was three (3) Registered Nurses (RNs), seven (7) Licensed Practical Nurses (LPNs), and 17 Certified Nurse Aides (CNAs). The assessment did not indicate specific staffing needs for each shift, based on changes to its resident population. Further review revealed the Facility Assessment did not include any information or plans regarding staff recruitment and retention, and did not include contingency plans for events that do not require the emergency operations plan to be activated. On 1/16/2025 at 5:01 PM, during an interview with the Administrator, he confirmed the Facility Assessment did not break down the facility's needs regarding staffing based on the different shifts, time of day, needs of the residents. He also confirmed it did not address a plan for recruitment and retention of staff or address contingency plans for events that do not require activation of emergency operations. He stated that he completed a form or template every year and had completed this one in July 2024 prior to the revision of the regulations that occurred in August of 2024.

50751 Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene when a Licensed Practical Nurse (LPN) did not wash her hands or change her gloves during Percutaneous Endoscopic Gastrostomy (PEG) care for one (1) of (1) resident reviewed for care. Resident #22. Findings included: A review of the facility's policy titled Wound Care undated, revealed, .Steps in the Procedure .Wash and dry your hands thoroughly . Loosen tape and remove dressing. Discard soiled dressing and gloves into appropriate receptacles. Wash and dry your hands thoroughly. Put on gloves . On 01/15/2025 at 3:46 PM, during an observation of PEG site care and interview with LPN #2 revealed LPN #2 did not change gloves throughout the procedure. LPN #2 used the same gloves to remove the soiled dressing, cleanse the site, and pat the site dry. LPN #2 confirmed that she did not change gloves during the procedure and acknowledged that gloves should have been changed between removing the soiled dressing and cleaning the site. On 01/16/2025 at 9:55 AM, during an interview, Registered Nurse (RN) #1, the Infection Preventionist (IP), stated that LPN #2 should have changed her gloves multiple times during the procedure. RN #1 explained that gloves should be changed when removing the old dressing, before cleaning the site, and prior to applying a new dressing to reduce the risk of cross-contamination and infection at the PEG tube site. On 01/16/2025 at 10:15 AM, during an interview, the Assistant Director of Nursing (ADON), RN #2, confirmed that gloves should have been changed between removing the old dressing and cleansing the site. RN #2 stated that failure to change gloves could lead to touching a clean site with contaminated gloves, increasing the risk of infection. A record review of the Admission Record revealed the facility admitted Resident #22 on 05/30/2024 with current diagnoses including Gastrostomy Status. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/2024 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident's cognition was moderately impaired. Further review of the documentation in Section K revealed Resident #22 had a feeding tube (PEG). A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #22 had a physician's order, dated 6/26/24, to clean the PEG site daily.

Based on observation, interviews, record reviews and facility policy review the facility failed to implement the comprehensive care plan related to a resident's food preferences for one (1) of 19 sampled residents. Resident #12 Findings include: A record review of the facility's policy Using the Care Plan, undated, revealed. The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . Policy Interpretation and Implementation .6. Documentation must be consistent with the resident's care plan . Record review of the Face Sheet revealed the facility admitted Resident #12 on 05/01/2018 and he had diagnoses including Hypokalemia, Chronic Ischemic Heart Disease, and Dysphagia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/23 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Record review of the Care Plan for Resident #12 revealed a Problem/Need of At risk for nutritional deficit . with a Problem Onset of 6/15/20 and an Approach to Honor food preferences. On 08/14/23 at 12:00 PM, during an observation and interview, Resident #12 was observed eating lunch in his room. He stated that he received a pork chop on his meal tray, but he did not eat pork. He explained that a Certified Nurse Aide (CNA) had taken the pork chop off his plate and had thrown it in the garbage. An observation revealed there was a porkchop in the trash can. An observation of the meal tray card for Resident #12 revealed pork was listed as a Dislike. Resident #12 commented that there is only so much chicken strips he can eat and he did not like burgers or spicy foods. On 08/17/23 at 10:00 AM, during an interview with Dietary #2, she explained she got the dietary likes and dislikes of all new admissions for the admission assessment. She explained Resident #12 had changed his mind several times on his likes and dislikes. Dietary #3 reviewed Resident #12's meal tray card and confirmed that pork is listed as a dislike. She stated that because the resident got a pork chop on his lunch meal tray on 8/14/23, his food preferences were not honored, and the care plan was not followed. On 08/17/23 at 10:20 AM, during an interview with the Administrator, he explained that he expected the facility staff to follow residents' plan of care related to food preferences. On 08/17/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she expected all staff to follow the resident's care plan. On 08/17/23 at 04:55 PM, during an interview with Registered Nurse (RN) #2, she explained that she expected all staff to follow care plans to meet resident needs and if a resident requested something different, the care plan would be updated to ensure resident choices were honored.

Based on observation, interviews, record reviews, and facility statement review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of two (2) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. Resident # 43. Findings include: The facility provided a written statement on letterhead and signed by the Director of Nurses (DON), that the facility does not have a policy that states which discipline can turn a feeding pump on or off. On 8/14/23 at 10:54 AM, Certified Nursing Assistant (CNA) #1 was observed placing Resident #43's enteral feeding pump on hold. The CNA then repositioned the resident by turning her from her right side to her left side. After the resident's care was completed, CNA #1 turned Resident #43's enteral feeding pump back on. On 8/14/23 at 11:00 AM, in an interview with CNA #1, she confirmed that she had put Resident #43's feeding pump on pause, but stated she is allowed to pause and restart the pump, but she is not allowed to turn the pump off. On 08/15/23 at 1:28 PM, during an interview with Licensed Practical Nurse (LPN) #2, she confirmed that only nurses should turn the feeding pump on, off or pause. She stated it is outside of the scope of practice for a CNA a to operate the pump, such as turning it on, off or pausing it. On 8/15/23 at 1:45 PM, in an interview with the Director of Nursing (DON), she confirmed CNAs are not allowed to operate the feeding pump in any capacity. The DON stated the CNA touching the feeding pump is outside her scope of practice. She also revealed the CNAs should have a nurse come in to assist with the feeding pump when turning the Resident. Record review of the Face Sheet of Resident #43 revealed the facility admitted the resident to the facility on [DATE]. The resident's current diagnoses included Parkinson's disease, Dysphasia, and Contractures of Muscle, Multiple Sites. Record review of Physician Orders, for the month of August, 2023 revealed an order for Isosource 1.5 calories @ 65 ML/HR (milliliters per hour) times 22 hours (hold time two hours for gut rest from 8:00 -10:00 AM).

Based observation, interviews, record review, and facility policy review the facility failed to support the nutritional well-being for a resident while respecting an individual's right to make choices about his or her diet for one (1) of 19 residents sampled. Resident #12 Findings include: A record review of the facility's policy Food and Nutrition Services, revised October 2017, revealed .Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Policy Interpretation and Implementation 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits . 4. Reasonable efforts will be made to accommodate resident choices and preferences . A record review of the facility's policy Substitutions, revised April 2007, revealed . Food substitutions will be made as appropriate or necessary . Policy Interpretation and Implementation .3. Residents' likes and dislikes will be considered when making substitutions . On 08/14/23 at 10:38 AM, during an interview with Resident #12, he explained that he had family to bring food into the facility because the food was not good, and the kitchen brought him foods that he did not like. He reported that the dietician came around and asked him questions including his likes and dislikes, but the kitchen continued to bring food he did not like. On 08/14/23 at 12:00 PM, during an observation and interview, Resident #12 was observed eating lunch in his room. He stated that he received a pork chop on his meal tray, but he did not eat pork. He explained that a Certified Nurse Aide (CNA) had taken the pork chop off his plate and had thrown it in the garbage. An observation revealed there was a pork chop in the trash can. An observation of the meal tray card for Resident #12 revealed pork was listed as a Dislike. Resident #12 commented that there is only so much chicken strips he can eat and he did not like burgers or spicy foods. On 08/17/23 at 09:35 AM, during an interview with CNA #3, he explained Resident #12 was very specific on what he wanted to eat and that he did not eat pork. He confirmed that on 08/14/23, Resident #12 received a pork chop on his lunch tray. CNA #3 said he asked the resident if he wanted him to just take it off the plate, and the resident did so he just threw it away in the garbage. CNA #3 was unable to recall if Resident #12 had asked for anything else. On 08/17/23 at 09:45 AM, during an interview with Dietary #1, he explained he was unable to remember what Resident #12 had asked for at lunch on 08/14/23. Dietary #1 explained that he sees all the residents and writes down their requests, but he does not keep it past the day. He stated that he does not know all of Resident #12's likes and dislikes, but they should be listed on his meal tray card. On 08/17/23 at 10:00 AM, during an interview with Dietary #2, she explained she got the dietary likes and dislikes of all new admissions for the admission assessment. She explained Resident #12 had changed his mind several times on his likes and dislikes. Dietary #2 reviewed Resident #12's meal tray card and confirmed that pork is listed as a dislike. She stated that because the resident got a pork chop on his lunch meal tray on 8/14/23, his food preferences were not honored, and the care plan was not followed. On 08/17/23 at 10:20 AM, during an interview with the Administrator, he explained he expected the kitchen and dietary staff to honor a resident's likes and dislikes of food and choices. On 08/17/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she expected the staff to offer to replace a food item if a resident asked for it to be thrown away. She stated that all staff should respect and honor a resident's likes and dislikes of food and choices and should notify the kitchen staff and management if any problems occur. Record review of the Face Sheet revealed the facility admitted Resident #12 on 05/01/2018 and he had diagnoses including Hypokalemia, Chronic Ischemic Heart Disease, and Dysphagia. Record review of the meal tray card for Dinner Wednesday 08/16/23 for Resident #12 revealed Pork was listed under the Dislikes column. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/23 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to make prompt efforts to resolve a resident's grievance for one (1) of 21 residents reviewed, Resident #33. Findings include: A review of the facility's Filing Grievances/Complaints policy, dated 2001, revealed the facility would help residents, their representatives, other interested family members or resident advocates file grievances or complaints when such requests are made. The policy revealed, the Administrator has delegated the responsibility of grievance and/or complaint investigations to Social Services. Upon receipt of a grievance and/or complaint, Social Services will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and /or complaint. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any need to be taken. The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his/her designee will make such reports orally upon completion of investigation. On 02/03/2020 at 2:27 PM, during an interview with Resident #33, he revealed that he had $20.00 dollars missing, which was given to him in (MONTH) 2019 for Christmas. Resident #33 stated he and his Resident Representative talked to the Administrator in mid (MONTH) 2020. Resident #33 stated the Administrator told him that he would see if he could give the money back. Resident #33 revealed the Administrator had not gotten back with him. During an interview, on 02/06/2020 at 10:28 AM, Resident #33 revealed that his niece was his Resident Representative (RR). Resident #33 stated he discovered the money was missing from the zipper section of his bible case, when he went to pay a deacon for some chicken he had brought to him. On 02/06/2020 at 10:44 AM, an interview with Resident # 33's RR revealed, she had spoken to the Administrator two (2) times in reference to the Resident money missing. The RR stated, the first time she spoke with the Administrator he told her that he would have to talk to somebody about getting the money replaced. The RR stated the Administrator never got back with her. The RR revealed she and Resident #33 had a face to face meeting with the Administrator in mid January. She stated during the meeting, the Administrator stated that he would look into giving Resident #33 his money back. The RR stated she called the Administrator on 02/05/2020, and he stated that he had to talk to someone about it. The RR revealed the Administrator still had not done anything about replacing the money. On 02/06/2020 at 11:18 AM, during an interview, the Administrator stated that he didn't know if Resident #33 actually had the money. The Administrator further stated if you give money back to one resident then everybody would say they had money missing. The Administrator stated, We can't be responsible for his money. The Administrator revealed he told Resident #33 and the RR they could put the money in a trust account. The Administrator stated he had phoned the facility's Corporate office and had not got a response. The Administrator revealed he had forgotten about it until Resident #33's RR called him on yesterday. The Administrator stated he had opened an investigation. The Administrator was asked for a copy of the investigation, but unable to present it to the surveyor. The Administrator revealed he had given the investigation report to the Director of Nursing (DON). During an interview, on 02/06/2020 at 11:20 AM, the DON revealed she didn't know anything about Resident #33 missing money and had not gotten any paperwork from the Administrator. On 02/06/2020 at 11:30 AM, during an interview with the Administrator, he stated he didn't know he needed to file a grievance. The Administrator stated Resident #33's RR had told him she didn't want him to file a grievance. The Administrator revealed that they sometimes file grievances and sometimes they don't. The Administrator revealed he had not contacted the facility's Corporate office again. On 02/06/2020 at 11:39 AM, Resident #33's RR revealed she did not tell the Administrator not to file a grievance. On 02/06/2020 at 11:55 AM, an interview with the Licensed Social Worker (LSW) revealed, she did not know anything about Resident #33's missing money.

Based on staff interview, record review, and facility policy review, the facility failed to revise the care plan related to falls for one (1) of 21 resident care plans reviewed, Resident #43. Findings include: Review of the facility's Care Plans-Comprehensive policy, not dated, revealed care plans are revised as information about the resident and the resident's condition changes. Review of Resident #43's care plan related potential for falls, onset date of 10/31/2019, revealed it was not updated to reflect falls that occurred in (MONTH) 2019 or any added interventions. Review of Resident #43's Resident Incident Reports revealed falls occurred on 12/02/2019, 12/27/2019, and 12/30/2019. Interventions from these incident reports included to encourage and instruct resident to call for assistance, encourage to use wheelchair when resident is weak, which were not included on the current care plan. During an interview, on 02/06/2020 at 11:33 AM, Licensed Practical Nurse (LPN) #1, revealed she was usually notified about residents falls in the morning meetings with staff, and then the Director of Nursing (DON) would bring the incident reports to her to sign and review. LPN #1 stated she would then add the falls and interventions to the care plan. LPN #1 confirmed the comprehensive care plan currently on the medical record did not address Resident #43's most recent falls. On 02/06/2020 at 12:24 PM, during an interview, the DON stated it was the facility's policy to update the care plan in the computer for each fall and new intervention. The DON stated it was important to update the care plan related to each fall to possibly prevent further falls. The DON revealed the Resident #43's care plan should have been updated as per policy, and it wasn't done.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the potential spread of infection by failing to provide a barrier on a resident's bed side table during a finger stick glucometer test, for one (1) of four (4) finger stick observations. Findings include: Review of the facility's Blood Sampling policy, dated April, 2012, revealed the blood glucose monitoring device should be placed on a clean field. On 1/23/18 at 4:26 PM, an observation of Licensed Practical Nurse (LPN) #1 revealed the glucometer was placed in a plastic container that was sitting on the medication cart. The medication cart was in the hall, outside of the resident's room. LPN #1 carried the plastic container into Unsampled Resident A's room, and placed the container on the over bed table without cleaning the table top, or placing a surface barrier down. LPN #1 performed the finger stick, and returned the contaminated plastic container, which contained the cleaned glucometer, to the medication cart without cleaning the container. LPN #1 proceeded to take the contaminated plastic container into the next resident's room, and placed it on the resident's bedside table, without the use of a barrier, and then returned the container to the medication cart, again without cleaning it before setting it on the med cart. LPN #1 did not clean the medication cart after setting the contaminated container on it. On 1/25/20/18 at 4:22 PM, an interview with LPN #1 confirmed she did not place a barrier down before placing the plastic container on the over bed table in Unsampled Resident A's room. LPN #1 confirmed she did not clean the plastic container before placing it on top of the medication cart, or taking the container into the next resident's room. LPN #1 revealed she had been in-serviced on infection control during medication pass. On 1/25/2018 at 4:53 PM, an interview with the Director of Nursing (DON) confirmed the LPN should use a barrier when taking items into a resident's room before placing the items on an over bed table, or clean them before placing back on the medication cart, or into another room. The DON revealed the nurses have been in-serviced on infection control during a medication pass.

Based on observation, staff interview, facility policy review, and facility in-service record, the facility failed to store serving trays in a manner to prevent wet nesting for four (4) of 12 pans inspected; one (1) of three (3) dietary department tours; and, failed to maintain dish storage racks free from dust and debris for two (2) of three (3) dietary department tours. Findings include: Review of the facility's Machine Ware Washing policy, with a revision date of 6/14, reads under 4. Part D. All dishes, glassware, and silverware are air dried. Review of facility in-service record, hosted by Dietary Manager (DM) titled, Wet Nesting, dated 10/1/16, reads, Items must be allowed to air dry before being stacked or stored. All dietary staff in were in attendance per signature. Observation of dietary department on 10/12/16 at 10:30 AM, revealed metal shelving that contained drinkware and cutting boards. The shelving contained a buildup of dust and other unidentifiable debris. The drinkware was stored upside down and in direct contact with these potential physical contaminates. There was also an accumulation of rust on the supporting legs of the shelving. A second observation of the dietary department was made on 10/13/16 between 10:30 - 10:40 AM, with the Dietary Manager in attendance. The dirty and rusty metal shelving containing the drinkware was pointed out to the DM. There were also, on this observation, serving pans found to be wet nested. Out of a total of 12 stainless serving pans stacked together, four (4) of them contained water trapped inside. During an interview on 10/13/16 at 11:40 AM, and again at 2:20 PM, the Dietary Manager acknowledged the presence of the dirty and rusty shelving and confirmed this to be a potential physical contamination risk. She stated the shelving would be removed from service and cleaned, immediately. During this same interview, she stated that she could not believe that the pans were wet nested. She said, I preach about this all the time. She stated we have recently in-serviced on this. They know better.

Based on observation, record review, staff interview and the facility's policy review the facility failed to ensure ordered medication was available as ordered by the physician for one (1) of nine (9) resident medication administrations observed (Resident #2). 21 missed doses out of 42 opportunities. Findings include: Review of the facility's Medication ordering and Receiving from the Pharmacy policy, dated November 2011, revealed the refill order is scanned in to the pharmacy. The bar code can be peeled off and attached to an order for [REDACTED]. The policy also noted a nurse assures medications are incorporated into the resident's specific allocation prior to the next medication pass. Record review for Resident #2 revealed a physician's orders [REDACTED]. On 10/13/16 at 4:15 PM, an observation/interview with Licensed Practical Nurse (LPN) #2 during medication administration for Resident #2, revealed Eliquis 5 mg not administered. LPN #2 revealed It not here. I don't have a card, I don't know when it ran out. I am sure they ordered it on the day shift because she had gotten it in the past. On 10/14/16 at 7:30 AM, an interview/ Observation with LPN #1 about Eliquis for Resident #2 revealed, I came back Monday (10/10/16) and she didn't have any. On 10/14/16 at 8:30 AM, an interview with Pharmacy (contact for facility) about the Eliquis, revealed, they had sent 6 doses on 9/23/16 and 6 doses on 10/13/16. The Pharmacy person stated they could only send 6 doses because Resident #2 had no coverage and needed a PA (Prior Approval) number and the nursing home had not gotten the number yet so only 6 pills could be sent. On 10/14/16 at 9:00 AM, an interview the DON revealed she knew on 10/7/16 that no Eliquis was available for Resident #2 and thought she had talked with the Pharmacist on 10/10/16. The DON stated she needed a PA number and told the Pharmacy to send the pills and the nursing home would pay for it. The DON stated she didn't hear anything else. The DON stated on 10/3/16 at 5:30 PM they (Pharmacy) sent 6 pills and on 10/6/16 they sent 6 pills. Review of the delivery manifest revealed six (6) Eliquis pills were sent from the Pharmacy on 10/3/16 and six (6) on 10/6/16. This would have left 6.5 days, or 13 doses not received in October. Four (4) days, or eight (8) doses, were not administered from 9/23/16-9/30/16, per Pharmacy interview. This made a total of 21 doses of Eliquis that Resident #2 did not receive that was ordered. Review of the facility's face sheet revealed the facility admitted the resident on 8/24/16. Resident #2's [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/31/16, revealed Resident #2 had a Brief Interview of Mental; Status score of 15 indicating independent cognition.

Based on record review, staff interview and the facility's policy review, the facility failed to develop a comprehensive care plan as evidenced by no care plan for code status for one (1) of 14 resident records reviewed (Resident #8). Findings include: Review of the facility's Care Plans-Comprehensive policy, dated December 2010, revealed each resident's care plan is designed to reflect the resident's expressed wished regarding care and treatment goals. Record review for Resident #8's comprehensive care plans failed to reveal a care plan indicating code status. Review of Resident #8's October 2016 physician's orders [REDACTED]. On 10/13/16 at 1:15 PM, an interview the Registered Nurse (RN) #1 revealed, I do not write the care plans, whoever takes the order should add it to the care plans. I update them on annuals and sign significant changes by deleting or typing the hand written stuff. If there is not one the nurse did not write one. Interview with the Director of Nursing on 10/14/16 at 9:00 AM, confirmed Resident #1's code status of DNR. Review of the facility's face sheet revealed the facility admitted the resident on 10/22/15. Resident #8's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/16, revealed Resident #8 had a Brief Interview of Mental Status score of 14 indicating the resident had independent cognition.

Based on policy review, complaint intake review, staff interview, and observation, the facility staff failed to promptly notify the physician and the responsible party for one (1) of three (3) residents sampled for wandering. (Resident #1). On 4/25/14 at approximately 2:15 PM, Resident #1, who had a [DIAGNOSES REDACTED]. Resident #1 ambulated approximately four tenths (.4) of a mile from the facility on a busy city street. The facility's failure to notify the physician had the likelihood to result in serious injury, harm, impairment, or death to Resident #1 and other residents due to the lack of assessment and oversight of a physician after being missing from the facility unsupervised. The facility's failure to notify the Responsible Party (RP) prevented the RP from making potential safety decisions. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/25/14. The facility's Administrator was notified of the IJ and Substandard Quality of Care (SQC) on 10/17/14. An acceptable credible Allegation of Compliance was received on 10/18/14 in which the facility alleged the IJ was removed on 10/18/14. The State Survey Agency determined the IJ was removed on 10/19/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.10 (F157), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy "Change in a Resident's Condition or Status" revised April 2014, revealed, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status (e.g., changes in level of care, billing/payments, resident rights, etc.)." The facility policy entitled "Elopements", revised December 2007, revealed staff shall investigate and report all cases of missing residents. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall (a) Examine the resident for injuries, (b) Notify the Attending Physician; (c) Notify the resident's legal representative (sponsor) of the incident, (d) Complete and file Report of Incident/Accident; and (e) Document the event in the resident's medical record. The facility policy entitled "Elopement Drill Policy and Procedure", not dated, stated "Also in a real elopement, when the resident is found a complete body audit is completed to assess for injuries or distress. The family, doctor, Administrator and DON (Director of Nursing) will be notified." Review of an anonymous complaint made to the State Agency on 10/02/14 revealed, "an elder (name of Resident #1) got out of the building in May 2014 and the maintenance man brought her back and she (Administrator) refused to report it." Interview on 10/16/14 at 11:15 AM with the Environmental Services Supervisor (ESS)confirmed Resident #1 was found outside of the facility. He stated while driving on (name of street), he saw Resident #1 walking. He said he picked her up in the facility bus that he was driving and returned her to the facility. The ESS did not remember the exact date of the incident. Interview on 10/17/14 at 9:10 AM with the facility Administrator revealed in response to the question was the Physician notified, the Administrator stated she was not sure, to ask the Director of Nursing (DON). When asked if the family was notified, the Administrator answered that they were not able to get in touch with the son, ask the DON. Interview on 10/16/14 at 11:50 AM with the DON stated she had not notified the physician or the responsible party. Interview by telephone on 10/17/14 at 11:45 AM with Resident #1's physician revealed he was not notified of the resident leaving the facility unsupervised on the date of the incident (4/25/14). He stated he was notified this morning (10/17/14). When the physician was asked if the resident would be at risk by being without supervision and walking on (name of street) he responded "yes". Interview by telephone on 10/16/14 at 10:40 AM with the son of Resident #1 revealed the facility had never informed him that his mother had left the facility unsupervised. Observation on 10/16/14 at 4:45 PM of Resident #1 revealed she was ambulating independently in the hallway with a steady gait. When questioned about how it was decided that the incident would not be reported as required, the Administrator replied that the resident had been okay and the family was not involved. She was questioned as to how the family not being involved influenced her decision to not report she responded "it just did". During an interview on 10/17/14 at 10:40 AM, the Administrator was asked whose responsibility it was to report the 4/25/14 incident, she responded that anyone can report but that she takes primary responsibility for reporting. The Administrator was asked if she was aware that she needed to report to the Attorney General's office and to the State Agency she responded yes. Record review for Resident #1 revealed the facility admitted the resident on 7/17/09 with [DIAGNOSES REDACTED]. Review of the 3/28/14 Minimum Data Set Assessment (in effect at the time of the incident) revealed Resident #1 was independent with transfers and ambulation. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on interviews, record reviews, facility policy and procedure reviews, and observations, the facility failed to operate according to the existing facility abuse policy and the facility failed to implement and failed to follow their policies and procedures for investigations for one (1) of three (3) residents reviewed for investigations after an elopement incident and for not reporting as required to authorities. On April 25, 2014 Resident #1 eloped from the facility without the facility's knowledge. Resident #1 was discovered alone, walking the busy streets of a major business area of the city several blocks away from the facility (approximately four tenths (.4) of a mile from the facility). Resident #1 was picked up and driven back to the facility where it was brought to the facility's attention that Resident #1 had eloped. Resident #1 had a documented medical [DIAGNOSES REDACTED]. Resident #1 was assessed by the facility as a high risk for wandering for attempting to leave the facility unsupervised. Resident #1 was care planned by the facility as a wandering Resident in need of supervision and a "wander-guard" security alarm bracelet had been placed on Resident #1 in order to minimize the chances for elopement. The facility's failure to operate according to the existing facility abuse policy and the facility's failure to implement and follow their established policies and procedures resulted in the likelihood of serious harm. injury, impairment or death to Resident #1 and other residents assessed at risk for wandering. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/25/14. The facility's Administrator was notified of the IJ and Substandard Quality of Care (SQC) on 10/17/14. An acceptable credible Allegation of Compliance was received on 10/18/14 in which the facility alleged the IJ was removed on 10/18/14. The State Survey Agency determined the IJ was removed on 10/19/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.13(c) (3) Investigation, 42 CFR 483.13(c) (1) (iii) Reporting (F226), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the "(Facility Name) Abuse Policy", updated 8/09, revealed, "It is the policy of (facility name) that any type or form of resident abuse or mistreatment will not be tolerated. (Facility Name) holds the right, in any situation concerning abuse of a resident to immediately terminate an employee from this nursing home. This facility has developed and implemented this policy and the following procedure to include the necessary components of employee screening, training, prevention, identification, protection of rights and method of reporting and appropriate response. Procedures: Investigation: (Facility Name) will identify and investigate all incidents, including the staff member responsible for reporting. An investigation of any alleged violations will be conducted and this facility will give an account of the findings to the proper authorities. Reporting/Response. (Facility Name) will take action that consists of the following reporting/response procedures: Report all alleged violations and substantial incidents to the State agency and any other agencies as required. Corrective proceedings will be taken, depending on the conclusion of the investigation. Evaluate the incidence to establish adjustments needing to be applied, if any, to existing policies and procedures to avoid further occurrences." Review of the "Reporting Abuse or Neglect Procedure" revealed abuse or neglect was to be reported to "Department of Health Licensing and Certification Hotline and to (the) Attorney General". The procedure continued "Report within 24 hours of incident, complete investigation within 72 hours of incident." The procedure concluded by instructing the staff to "fax completed investigation to" and provided the Attorney General's and Licensing and Certification's fax numbers. Interview on with the Environmental Services Director revealed Resident #1 had left the facility without the supervision of facility staff. He did not remember the date of the incident. He stated that he had been driving the facility bus to obtain supplies for the facility. He remembered that the incident was on a Friday afternoon after 2:00 PM. He was driving on a local street and noticed Resident #1 at the corner of that street. He said he recognized the resident by a pink cap that she sometimes wore. He reported he made a u-turn and picked the resident up and returned her to the facility. Interview on 10/16/14 at 11:50 AM with the Director of Nursing (DON) confirmed that in April or May she had been called outside to the bus where Resident #1 and the Administrator were sitting. The Administrator told the DON that Resident #1 had been picked up by the Environmental Services Director on the street. The DON stated that she had not investigated the incident nor had she reported the incident to the State Agency or the Attorney General's office. On 10/16/14 at 3:00 PM the DON remembered the date of the incident by looking back at an in-service she had conducted on 4/25/14. On 10/16/14 at 11:40 AM the Administrator was asked for her investigation of the 4/25/14 incident. The following statement was provided: "I do not recall the date that (Resident #1) eloped from (Facility Name). I believe it was at the end of April, 2014. Ms. (Resident #1) was picked up by (name of Environmental Services Director) on (Name of Street) one afternoon and returned to (Name of Facility). She was not able to answer any questions related to where she was going due to her mental status. Her daily behavior includes wandering and stating that she needs to go somewhere and see someone about something every day. The staff is very well aware of her behavior, and loves her dearly. She was not hurt upon her return. Her Code Alert bracelet was checked and working properly. I reviewed the code alert processes and all equipment was checked to be sure that it was working properly. I checked to see that the elopement log was being completed. Staff was in-serviced on April 25, 2014 following this incident on elopement, wandering, and monitoring. The in-service included a review of the Elopement Drill, Policy and Procedures. All were reminded to watch Ms. (Resident #1) carefully, and be sure they know where she is. She was and continues to be monitored every shift for wandering. I did not record any notes related to this incident, nor did I report this as abuse following this incident." On 10/17/14 at 9:10 AM the Administrator was asked if the 4/25/14 incident could be considered neglect according to the definition of neglect. She responded that it could be considered an accident also. When asked why she thought the incident would be an accident she responded "she got out". The Administrator was asked how it was decided that the incident would not be reported. She responded the resident was okay and the family was not involved. She was asked how the family not being involved influenced her decision and she responded "It just did". The Administrator stated that the resident may have been out of the facility 20 minutes. On 10/17/14 at 10:40 AM, the Administrator was asked whose responsibility it was to report. She stated anybody could report but she took primary responsibility. Observation on 10/16/14 at 4:45 PM of Resident #1 revealed she was ambulating independently in the hallway with a steady gait. Record review for Resident #1 revealed she was admitted to the facility 7/17/09 with [DIAGNOSES REDACTED]. Review of the 3/28/14 Minimum Data Set Assessment (in effect at the time of the incident) revealed that Resident #1 was independent with transfers and ambulation. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on record review, policy review, interview, and observation, the facility failed to review and revise Resident #1's care plan after she left the building unsupervised on 4/25/14 to provide new approaches to prevent further occurrences of the incident for one (1) of three (3) residents reviewed for wandering. On 4/25/14, Resident #1, who had a [DIAGNOSES REDACTED]. The resident was returned to the facility by the Environmental Services Supervisor. The facility's failure to revise the resident's care plan after elopement was likely to result in serious injury, harm, impairment, or death to Resident #1 and other residents assessed for wandering. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/25/14. The facility's Administrator was notified of the IJ on 10/17/14. An acceptable credible Allegation of Compliance was received on 10/18/14 in which the facility alleged the IJ was removed on 10/18/14. The State Survey Agency determined the IJ was removed on 10/19/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (k)(3)(ii), (F282), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility policy, "Care Plans-Comprehensive", revised October 2010, stated, "An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident." "The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when the desired outcome is not met." Review of the Resident #1's care plan effective on 4/25/14 when the resident left the facility unsupervised revealed that the resident was care planned for the problem of "Episodes of wandering as evidenced by attempts to leave the facility unattended." This problem had an onset date of 10/10/13. Dates indicating the review of this problem were 10/17/13, 1/6/14, 3/26/14, and 6/23/13. Each time the care plan was reviewed the statement "Continue POC" (plan of care) was written. Review of the care plan for "Altered thought process R/T (related to) impaired cognition, [MEDICAL CONDITION]" was identified on 10/10/13 was revised 4/19/14 prior to the incident. The care plan identified the problem of "Episodes of wandering as evidenced by attempts to leave facility unattended" was identified on 10/10/13. Record review of the comprehensive care plans for Resident #1 revealed no new approaches after the incident of 4/25/14 when Resident #1 left the building unsupervised. Interview on 10/17/14 at 11:40 AM, with the Social Services Director, identified as the person responsible for up-dating the care plan for wandering, revealed he knew of Resident #1 leaving the facility unattended after the fact. He agreed the care plan should have been revised after the 4/25/14 incident but was not. Observation on 10/16/14 at 4:45 PM of Resident #1 revealed she was ambulating independently in the hallway with a steady gait. Record review for Resident #1 revealed she was admitted to the facility 7/17/09 with [DIAGNOSES REDACTED]. The facility admitted Resident #1 on 7/17/09. Review of the resident's Face Sheet revealed Resident #1 had a [DIAGNOSES REDACTED]. Review of the 3/28/14 Minimum Data Set Assessment (in effect at the time of the incident) revealed that Resident #1 was independent with transfers and ambulation. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on record review, policy review, interview, and observation, the facility failed to provide adequate supervision to prevent a resident from leaving the facility without authorization and without the benefit of staff supervision. (Resident #1) The resident had [DIAGNOSES REDACTED]. The resident was assessed at risk for wandering and trying to leave to facility unattended. Resident #1 left the facility alone and ambulated approximately .4 of a mile to a busy city street. The staff was unaware the resident was missing from the facility. The resident was seen by the Environmental Services Supervisor and was returned to the facility. The facility's failure to provide supervision to prevent the resident from being outside the facility unsupervised and failure to implement its policy and procedures and develop a plan of action to prevent a recurrence was likely to cause serious injury, harm, impairment or death to Resident #1 and other residents assessed for wandering. The facility was notified on 10/17/14 of the Immediate Jeopardy at 42 CFR 483.25(H) (2) Supervision (F323). An acceptable Allegation of Compliance (AOC) was received on 10/18/14 in which the facility alleged removal of the IJ on 10/18/14. The State Survey Agency determined the Immediate Jeopardy was removed on 10/19/14 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (H) (2) F323 was lowered to the scope and severity of a "D" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy entitled "Elopements", revised December 2007, revealed staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation - When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall (a) Examine the resident for injuries; (b) Notify the Attending Physician; (c) Notify the resident's legal representative (sponsor) of the incident; (d) Complete and file Report of Incident/Accident; and (e)Document the event in the resident's medical record. Review of the facility policy entitled "Prevent Elopement or Wandering, Unsafe, Resident", revealed "the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." Review of the facility policy entitled "Elopement Drill Policy and Procedure" (no adoption date) revealed "Also in a real elopement, when the resident is found a complete body audit is completed to assess for injuries or distress. The family, doctor, Administrator and D.O.N. (Director of Nursing) will be notified." An anonymous complaint was received by the State Agency on 10/2/14 alleging that "An elder (Resident #1) got out of the building in May 2014 and the maintenance man brought her back and she (Administrator) refused to report it." On 10/16/14 at 8:40 AM the Director of Nursing (DON) and Registered Nurse #1, also the Minimum Data Set Assessment Nurse, stated they would check to see if a resident had left the facility. Interview on 10/16/14 at 3:00 PM with the Director of Nursing (DON) confirmed Resident #1 had left the building on 4/25/14. Interview on 10/16/14 at 11:15 PM with the Environmental Services Supervisor (ESS) revealed he was driving up (name of street) and saw Resident #1 walking after 2:00 PM. He picked up Resident #1 and returned her to the facility. She was wearing a pink cap that she sometimes wore which was what alerted him to the fact that it was Resident #1. The Administrator was notified. An attempt was made to determine how the resident left the building. The ESS stated a video was reviewed and it was determined the resident exited through the door by the office of the Director of Nursing. Staff probably put in the code to the door to let the paramedics out and the resident walked out behind them. The ESS did not remember the date, it was April or May, but did remember that it was on a Friday because he was going to get supplies for the weekend. He estimated that the resident was unsupervised from 5 to 12 minutes. On 10/17/14 at 2:20 PM, with the assistance of the ESS, the route Resident #1 took was observed. Resident #1 left from the door opening onto (street name) behind an ambulance crew as they were leaving the building. The area was noted to be through a residential area ending at the corner of two busy city streets. The distance was approximately four tenths (.4) of a mile from the facility. There was a school zone observed at this time. The school zone was busy due to school was being dismissed, and cars lined up waiting to pick up students. The street was a busy four lane city street with a speed limit of 30 miles per hour. The State Surveyor counted 19 vehicles, from all directions, passing the corner which was the approximate time the resident left the faciity on [DATE]. On 10/16/14 at 11:40 AM, the Administrator was asked for the facility's investigation of the 4/25/14 incident when Resident #1 left the facility unsupervised. On 10/16/14 at 2:15 PM, the Administrator stated she had not done an investigation of the 4/25/14 incident and submitted the following statement: "I do not recall the date that (Resident #1) eloped from (facility name). I believe it was at the end of April, 2014. (Resident #1) was picked up by (Environmental Services Supervisor) on (street name) one afternoon and returned to (the facility). She was not able to answer any questions related to where she was going due to her mental status. Her daily behavior includes wandering and stating that she needs to go somewhere and see someone about something every day. The staff is very well aware of her behavior, and loves her dearly. She was not hurt upon her return. Her Code Alert bracelet was checked to be sure that it was working properly. I reviewed the code alert processes and all equipment was checked to be sure that it was working properly. I checked to see that the elopement log was being completed. Staff was in-serviced on April 25, 2014 following this incident on elopement, wandering, and monitoring. The in-service included a review of the Elopement Drill, Policy and Procedures. All were reminded to watch (Resident #1) carefully, and be sure they know where she is. She was and continues to be monitored every shift for wandering. I did not record any notes related to this incident, nor did I report this as abuse following this incident." Interview on 11/17/14 at 9:10 AM with the Administrator revealed when asked if a body audit was performed when the resident was returned, the Administrator stated to ask the Director of Nursing (DON). When asked if an incident report was completed, the Administrator stated the DON was doing one today. When asked if the 4/25/14 incident had been documented in the medical record, she stated that she did not know. The Administrator was asked if the resident had authorization or supervision when she left the building. She replied, "no". The Administrator was asked if the 4/25/14 incident could be considered neglect she replied it could be an accident also. She was asked to explain why it could be an accident she stated "she got out". An Incident Report was reviewed regarding Resident #1 elopement from the facility unsupervised on 4/25/14. Incident Report was dated 10/17/14 (the day after the complaint survey began). The facility failed to provide any other Incident Reports related to the elopement dated 4/25/14. The Wandering/Elopement Assessment for Resident #1, dated 3/27/14, documented that Resident #1 wandered and verbalized she wanted to leave. The assessment conclusion determined the resident was at risk for elopement. Interview on 10/17/14 at 9:10 AM with the Administrator revealed the code alert system was checked when the resident was returned to the building. There was no documentation of this being done. The Administrator said a facility video was reviewed after the elopement, and it was determined Resident #1 left out the door by the Director of Nurses' (DON) office. Interview on 10/17/14 at 3:20 PM with the Administrator revealed the video of the incident on 4/25/14 was not copied or saved, and the video tape was recorded over every 12 hours. The video was no longer available for review. On 10/17/14 at 3:25 PM, the Director of Nursing (DON) confirmed during an interview that she had reviewed the facility video. The DON stated she saw on the video that while she was letting the ambulance attendants out, Resident #1 walked out behind them. She stated the video showed that she was turned toward the keypad and Resident #1 was against the wall out of her line of sight. Resident #1 hugged the wall and eased toward the door out of her line of sight. The DON stated the door alarm was sounding due to the length of time she had to hold the door open for the ambulance attendants to leave. The DON stated the video showed she was resetting the code pad when Resident #1 went behind her and got out. The alarm did not sound when Resident #1 exited the building. Interview on 10/17/14 at 10:00 AM with the Activities Director (AD) revealed Resident #1 was adamant about getting out. The AD stated sometimes the resident talked about looking for someone on the second floor, and there was no second floor to the facility. The Activity Director did not think Resident #1 was aware of her safety. Interview on 10/17/14 at 6:10 AM with Licensed Practical Nurse (LPN) #1 revealed Resident #1 usually slept at night, and the staff needed to keep an eye on her. She stated Resident #1 had never tried to leave the building. LPN #1 stated the resident was confused as to day and place. She stated Resident #1 could carry on a conversation but really was confused. Interview on 10/17/14 at 6:17 AM with LPN #2 revealed Resident #1 at one time pushed the door between rooms 7 and 8 making it alarm and while staff was checking that door, the resident ran to another hall in the facility and tried to exit a door on that hall. Both doors had an alarm but opened out to an enclosed courtyard. LPN #2 continued that when Resident #1 started walking staff never knew what she would do. LPN #2 stated the resident was confused and unaware that "it is not safe out there". On 10/17/14 at 6:50 AM Certified Nurse Aide (CNA) #1 stated Resident #1 liked to work, she had at one time been employed as a prison guard, so staff had to watch her for getting out. Interview on 10/16/14 at 12:30 PM with the Social Services staff stated Resident #1 walked well by herself, and she went to the state fair with a group from the facility. The SS stated the resident walked the length of the fairway and back and refused to use a wheelchair. The SS stated Resident #1 was confused about her family and had long term memory problems. Observation on 10/16/14 at 4:45 PM of Resident #1 revealed she was ambulating independently in the hallway with a steady gait. Review of the Nurses Notes for Resident #1 for approximately one week prior to 4/25/14 revealed: On 4/19/14 at 6:53 PM, "Some confusion noted, argumentative toward staff at times." On 4/21/14 at 7:54 PM "Alert with confusion noted." On 4/22/14 at 7:57 PM "Some confusion note." On 4/24/14 at 1:03 AM, "No change in cognitive status positive dementia with confusion." On 4/24/14 at 7:15 PM, "Some confusion noted, argues with staff and other elders." The facility admitted Resident #1 on 7/17/09. Review of the resident's Face Sheet revealed Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) for 3/28/14 documented Resident #1 was independent in all activities of daily living including ambulation. The Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on policy review, job description review, record review and interviews with the facility staff, the facility's administration failed to ensure the facility used its resources effectively to maintain the highest physical well being for one (1) of three (3) residents reviewed as evidenced by the Administrator's failure to follow the established facility policy for abuse/neglect and for the reporting of incidents of elopement. The practice of the facility not having an effective system to monitor the operation and implementation of the facility's established policy and procedure for abuse/neglect and for reporting the incident of the elopement of Resident #1 placed Resident #1 and all residents assessed at risk for wandering in a situation with the likelihood for serious harm, impairment, or death. This situation resulted in an Immediate Jeopardy (IJ) that began on 04/25/2014, after Resident #1 eloped from the facility without the knowledge and supervision of the staff. The State Survey Agency determined that the Immediate Jeopardy (IJ) was removed on 10/19/2014 prior to exit. The Scope and Severity for the Immediate Jeopardy (IJ) at 42 CFR 483.75 (F490) was lowered to a "D" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the job description for "Administrator", signed 10/17/14 by the current Administrator and submitted by the Administrator, stated "The purpose of this position is to establish and maintain systems that are efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner." "May include any and/or all of the following but not limited to operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations." "Development, maintain and implement operational policies and procedures to meet residents' needs in compliance with federal, state and local requirements. Develop a monitoring system to assure compliance with federal, state and local requirements." An anonymous report to the State Agency, dated 10/2/14, read, "A elder (name of Resident #1) got out of the building in May 2014 and the maintenance man brought her back, and she (Administrator) refused to report it". An interview on 10/16/14 at 11:15 AM with the Environmental Services Supervisor confirmed that he had picked up Resident #1 at the corner of two busy city streets, ambulating unsupervised, approximately four tenths (.4) of a mile from the facility. Interview with the Administrator on 10/17/14 at 9:10 AM revealed: When asked if a body audit was performed when Resident #1 returned to the facility she stated she did not know off the top of her head. The Administrator was asked for an incident report regarding the incident. She stated one was being done today (10/17/14). The Administrator was asked if the incident was documented in the medical record and she stated she did not know. When asked if the physician was notified of the incident? The Administrator was not sure. When asked if the family was notified of the incident? The Administrator responded they were not able to get in touch with the son. During an interview on 10/17/14 at 10:40 AM, the Administrator was asked whose responsibility it was to report the 4/25/14 incident. The Administrator responded that anyone could report, but she took primary responsibility for reporting. When asked if she knew that she needed to report to the Attorney General's office and the State Agency she responded, "yes". The Administrator was asked how it was decided that the incident would not be reported to the Attorney General's office and to the State Agency's office. She responded the resident was okay and the family was not involved. When asked how the family not being involved influenced her decision to not report she responded, "It just did". The Administrator was asked if the incident was addressed by the Quality Assurance Committee she responded, "no". The facility admitted Resident #1 on 7/17/09. Review of the resident's Face Sheet revealed Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) for 3/28/14 documented that the resident was independent in all activities of daily living including ambulation. Her Brief Interview for Cognitive Status was 13, cognitively intact. On 10/16/14 at 4:45 PM, Resident #1 was observed ambulating down the hall independently. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on policy review, record review, and interview, the facility failed to ensure medical records were complete and accurate for one (1) of three (3) residents sampled for wandering as evidenced by staff failure to document the 4/25/14 incident in the resident's medical record when Resident #1 left the facility unsupervised. The facility's failure to document the incident in the resident's medical record presented an inaccurate record of the resident's capabilities and the need to closely observe the resident whenever anyone was exiting the facility. This documentation failure was likely to result in serious harm, impairment, or death to Resident #1 or other residents assessed as at risk for wandering. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/25/14. The facility's Administrator was notified of the IJ on 10/17/14. An acceptable credible Allegation of Compliance was received on 10/18/14 in which the facility alleged the IJ was removed on 10/18/14. The State Survey Agency determined the IJ was removed on 10/19/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (F 514) was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled "Charting and Documentation", revised August 2008, documented, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition must be recorded." Review of the facility's policy "Elopements", revised December 2007, revealed "When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. Review of Resident #1's facility record revealed no documentation of the 4/25/14 incident. On 10/16/14 at 11:40 AM, the Administrator submitted a written statement reflecting she did not record any notes related to the 4/25/14 incident. Interview, on 10/17/14 at 9:10 AM, with the Administrator revealed she stated she did not know if the 4/25/14 incident had been documented in the medical record and referred the surveyor to the Director of Nurses (DON). Interview with the DON on 10/17/14 at 7:20 AM revealed when asked about documentation of the incident in the resident's medical record, the DON confirmed, "no" there was not any documentation. The facility admitted Resident #1 on 7/17/09. Review of the resident's Face Sheet revealed Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) for 3/28/14 documented that the resident was independent in all activities of daily living including ambulation. Her Brief Interview for Cognitive Status was 13, cognitively intact. On 10/16/14 at 4:45 PM, Resident #1 was observed ambulating down the hall independently. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

Based on policy review, observations, job description review, record review, and interviews with the facility staff, the facility failed to implement a Quality Assurance program that identified and corrected facility deficiencies after the unsupervised elopement of Resident #1 who was one (1) of three (3) residents reviewed for elopement risks as evidenced by the failure of the facility to have the Quality Assurance Program/Committee to review and revise Resident #1's action plans and failure to implement new systems.Resident #1 eloped from the facility unsupervised. The facility had no knowledge of Resident #1's elopement until after she was returned by a facility employee approximately 20 minutes after she had left the building walking unsupervised on the busy city streets. Two members of the Quality Assurance Committee were aware Resident #1 had eloped from the facility unsupervised on 4/25/14. The committee failed to address the problems and develop a plan of action to prevent a recurrence. The facility's failure to initiate Quality Assurance (QA) policies and procedures to address the elopement from the facility and to implement processes designed to prevent the same problem in the future resulted in the likelihood of serious injury, harm, impairment, or death to Resident #1 and other residents assessed at risk for wandering in the facility. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/25/14. The facility's Administrator was notified of the IJ and Substandard Quality of Care (SQC) on 10/17/14. An acceptable credible Allegation of Compliance was received on 10/18/14 in which the facility alleged the IJ was removed on 10/18/14. The State Survey Agency determined the Immediate Jeopardy was removed on 10/19/14 prior to exit from the facility. The Scope and Severity for the Immediate Jeopardy at 483.75 (o) (F520) was lowered to a "D" while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the "Quality Assessment and Assurance Committee" policy, revised December 2009, stated, "This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. Policy Interpretation and Implementation 1. The Administrator shall delegate the necessary authority for actions and processes to the Quality Assessment and Assurance Committee. 2. The committee shall be a standing committee of the facility, and shall provide reports to the Administrator a governing board (body). Goals of the Committee The primary goals of the Quality Assessment and Assurance Committee are: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan; 2. To oversee facility systems and processes related to improving quality of care and services; 3. To promote consistent facility systems and processes and appropriate practices in resident care; 4. To help identify negative outcomes relative to resident care and resolve them appropriately Committee Membership 3. The following individuals will serve on the committee: a. Committee Chairperson; b. Administrator; c. Director of Nursing Services; d. Medical Director; i. Environmental Services Representative; Committee Actions 1. The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility." An anonymous report was received dated 10/2/14 stating "An elder (name of Resident #1) got out of the building in May 2014 and the maintenance man brought her back, and she (Administrator) refused to report it". An interview, on 10/16/14 at 11:15 AM with the Environmental Services Supervisor, confirmed that he had picked up Resident #1 at the corner of (name of city street) and (name of city street) ambulating unsupervised approximately .4 (four tenths) of a mile from the facility. Interview with the Administrator on 10/17/14 at 9:10 AM revealed when the Administrator was asked if the incident was addressed by the Quality Assurance Committee she responded "no". Interview, per telephone, on 10/17/14 at 11:45 AM with the physician of the resident, also serving as the Medical Director, confirmed that he had not been notified of Resident #1 leaving the facility unsupervised until this morning. He also stated that the Quality Assurance Committee had not addressed the incident. The facility admitted Resident #1 on 7/17/09. Review of the resident's Face Sheet revealed Resident #1 had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] for Resident #1 documented that the resident was independent in all activities of daily living including ambulation. Her Brief Interview for Cognitive Status was 13, cognitively intact. Observation on 10/16/14 at 4:45 PM of Resident #1 revealed she was ambulating independently in the hallway with a steady gait. The facility submitted an acceptable credible Allegation of Compliance on 10/18/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance revealed the facility took the following actions to remove the Immediate Jeopardy. A. On October 17, 2014, the facility began in-services by the Director of Nursing for all staff. All staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff are in-serviced on all of the below before being allowed to return to work: 1. The definition of neglect 2. The abuse and neglect policy 3. Who is to report neglect 4. All current and new elders identified as an elopement risk, along with their care plan and specific interventions 5. The new elopement binders located at each nurse's station with pictures and other identifying information. 6. The new ambulance process. When an ambulance is expected the charge nurse will alert the other charge nurse. Charge nurses will immediately become aware of the location of all elders identified as an elopement risk and have staff stay alert of their movements. Charge nurses are responsible for assigning a staff member to monitor the ambulance door for the ambulance crew arrival, let them in, and properly close and reset the door alarms to prevent elopement. This in-service is now a requirement for all new employees, and part of New Employee Orientation. Employees will not be able to provide direct care until they are in-serviced. B. On October 17, 2014, Resident #1's care plan was updated by the Director of Social Services to include one-on-one monitoring during waking hours by staff assigned by the supervising or charge nurse on duty. C. On October 17, 2014, the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours. She contacted and scheduled additional staff for continued monitoring as care planned. D. On October 17, 2014 the Administrator phoned ambulance Supervisor #A and ambulance Safety Risk Manager for Jackson #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. On October 17, 2014, the Environmental Services Director completed a full audit of all 8 (perimeter) door alarms and code alert (key pad) systems to confirm all systems are working properly. F. On October 17, 2014, the Administrator called the Medical Director. G. At 4:00 pm on October 17, 2014, the Director of Nursing applied Code Alert bracelets to Resident A, B and C's arms. Resident C was very upset and demanded that it be removed Resident C's code alert bracelet was removed from his arm and placed on his wheelchair by the Director of Nursing. H. On October 17, 2014, the Social Services Director updated the care plans on all 4 of 4 Elders at risk for elopement. I. On October 17, 2014, the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing assessed 51 of 51 Elders for elopement risk, and additional interventions were immediately put in place when indicated. Three new residents: Resident A, Resident B, and Resident C, and Resident #1, made 4 of 4 residents identified as being at risk for wandering. J. On October 17, 2014 the Administrator was disciplined in writing by the Co-Chair of the Personnel Committee of the Board of Directors and Human Resources for not reporting an elopement to the AGO's office and the Licensing and Certification office. K. On October 17,2014, an emergency QA meeting was conducted by the Quality Assurance team, including: the Medical Director, who attended by conference call, along with the Director of Nursing, Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. The QA team reviewed the concerns related to the investigation of the incident, and reviewed the current policy on Preventing Elopement or Wandering, Unsafe Resident. The following revisions were made to the Preventing Elopement or Wandering, Unsafe Resident Policy: Added new wandering assessments to be done: upon admission, quarterly, upon hospital returns and prn as needed. Added monitoring of new admission: Visual monitoring sheets every 2 hours, Nursing documentation every shift, Temporary care plan for the first 14 days, followed by either resolving or updating the care plan All actions were approved by the Medical Director and the rest of the QA team. L. On October 17, 2014, pictures and identifying information for all 4 resident identified at risk for elopement were placed in an Elopement Monitoring Binder placed at each nurse's station by the Director of Nursing. M. On October 17, 2014, the Director of Nursing notified Resident #1's physician of the incident that occurred on April 25, 2014. On October 17, 2014 the Director of Nursing notified Resident #1's family member of the incident that occurred on April 25, 2014. N. On October 17, 2014, the Director of Nursing placed a bed alarm on Resident #1's bed to be used when sleeping to alert staff when Resident #1 attempts to arise and needs one-on-one supervision again. The charge nurse is responsible for calling in additional staff for one-on-one supervision as needed, and they have been in-serviced as to this responsibility. O. On October 18, 2014, the Administrator notified the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014. The Administrator will report all elopements and will continue to follow the law for reporting. The facility alleged compliance as of October 18, 2014. On 10/18-19/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. A. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheet provided by the facility's Director of Nursing validated all staff including licensed nurses, registered nurses, certified nursing assistants, food service, housekeeping, laundry, maintenance, business office, and contract staff were in-serviced on the definition of neglect; the abuse and neglect policy; who is to report neglect; all current and new elders identified as an elopement risk, along with their care plan and specific interventions: the new elopement binders located at each nurse's station; and the new ambulance process. B. The state surveyor validated by review of Resident #1's care plan that the care plan was updated to include one-on-one monitoring during waking hours by staff assigned by the supervisor or charge nurse on duty. C. Interview and observation by the surveyor validated the Assistant Director of Nursing assigned a certified nursing assistant to Resident #1 for one-on-one monitoring during waking hours and had contacted and scheduled additional staff for continued monitoring as care planned. D. Validation of a signed statement the Administrator submitted validated she had phoned the ambulance Supervisor #A and the ambulance Safety Risk Manager #B, of the necessity of the facility ambulance door being closed completely upon entrance and exit. E. The state surveyor validated with the Environmental Services Director all 8 (perimeter) door alarms and code alert (key pad) systems were working properly. F. Review of a signed statement by the Administrator and interview with the Medical Director validated that on October 17, 2014, the Administrator had called the Medical Director and notified him of Resident #1's elopement. G. The state surveyor validated by observation that Resident #1, Resident A, Resident B and Resident C had Code Alert bracelets in place. H. By review of the care plans and interview, the state surveyor validated the Social Services Director had updated the care plans on all 4 of 4 residents assessed as at risk for elopement. I. Review of facility documentation validated the MDS/Care Plan Coordinator, Director of Nursing and the Assistant Director of Nursing had assessed all Elders for elopement risk, and additional interventions were put in place. J. The state surveyor validated by review of the disciplinary form that the Administrator was disciplined in writing for not reporting an elopement to the Licensing and Certification office or the Attorney General. K. Review of a sign in sheet with content validated an emergency QA meeting was conducted by the Quality Assurance team, that included the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the MDS/Care Plan Coordinator, and the Administrator. L. Review of the elopement monitoring binder validated pictures and identifying information for residents identified at risk for elopement were in an Elopement Monitoring Binder at each nurse's station. M. The state surveyor validated the Director of Nursing notified Resident #1's physician and Resident #1's family member of the incident on April 25, 2014. N. The state surveyor validated the Director of Nursing had placed a bed alarm on Resident #1's bed to alert staff when Resident #1 attempted to rise during sleep. O. Interview with the Administrator validated notification of the Attorney General's Office via online reporting of Resident #1's incident on April 25, 2014.

CI MS # Based on observation, record review, interview and policy review, the facility failed to protect three (3) of six (6) residents reviewed from physical abuse (Residents #1, #3 and #4). Findings Include: Resident #1 Review of a self-reported incident from the facility revealed the following: "On 8/6/12. The 11/7 (11:00 pm to 7:00 am) shift noticed bruising on .... (Resident #1's) chest, and left jaw, this finding was reported. The DON (Director of Nursing) assessed .... Resident #1 at this time, it was noted that there was a bruise under her left eye and cheek, also bruising (was noted) on (the) right upper chest. There was no swelling, and ... (Resident #1) did not give indications of being in distress or pain. " "The DON investigated the incident by questioning the staff, and no other staff had observed any problems or aggressive behavior of ... (Resident #2) toward ... (Resident #1), other than the statement obtained from ... Certified Nurse Aide (CNA) #1) the carepartner assigned at the time of the reported incident .... " "...(Name of Hospital) was contacted and ... (Resident #2) was accepted for admission." Review of a handwritten statement dated 8/8/12 from CNA #1 revealed the following: "On Aug (August) 5 about 9:15 a.m. I was going to get a light (call light) when passing by Room ... (Resident #1's room) I saw ... (Resident #2) raise her hand to hit ... (Resident #1), I ask (asked) her what was she doing and she said that she was playing with her, entering the room I could see the fear on her (Resident #1's) face. So I told ... (Resident #2) that I would report what I had seen. So I went and let her nurse know. " Observation on 8/21/12 at 12:40 p.m. of Resident #1 revealed that she was sitting in the day room/T.V. room in a gerichair. Both hands were contracted. Interview on 8/21/12 at 2:35 p.m. with Certified Nurse Aide (CNA) #1 confirmed that she had written the above statement. CNA #1 related that on 8/5/12 that she had passed Resident #1's room and had seen her sitting in her gerichair with Resident #2 sitting next to her. Resident #2 raised her right hand and swung down "like a slap". CNA #1 entered the room and moved Resident #2 away from Resident #1. CNA #1 stated that Resident #1 was not capable of speaking but that she was upset. Her eyes were rolling and she was saying "da, da, da". The CNA stated that she then reported the incident to Licensed Practical Nurse (LPN) #1. Interview on 8/22/12 at 3:20 p.m. with LPN #1 regarding the 8/5/12 incident revealed that she had made rounds earlier that day and Resident #1 was O.K. About 11:30 a.m. that morning she noted that Resident #1 was bruised. The bruising was reported to the Registered Nurse Supervisor at that time. It was determined that Resident #2 had hit Resident #1 by interviewing CNA #1. LPN #1 stated that she does not remember if CNA #1 had reported the incident to her prior to her finding Resident #1 bruised. Review of the Minimum Data Set (MDS) assessment with the Assessment Reference Date (ARD) of 5/28/12 revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Hearing, Speech, Vision section of this MDS revealed that the speech clarity was coded "2. No speech-absence of spoken words". The resident's Cognitive Patterns summary score was "00" indicating that the resident's cognitive status was "Severe Impairment". Review of the functional status for this resident revealed that she was totally dependent on staff for all activities of daily living. Observation of Resident #2 on 8/21/12 at 12:35 p.m. revealed that she was sitting in a wheelchair in her room crying and complaining of a headache. It was noted that she had a right above the knee amputation. Review of the face sheet for Resident #2 revealed that she was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a cognitive assessment dated [DATE] and completed by the SS Coordinator revealed that the Brief Interview for Mental Status Summary Score was coded "15" indicating that Resident #2 was "Cognitively intact". Review of the current care plan for this resident revealed that "Elder requires set up help with eating; limited assist with transfers, dressing, and toileting, independent with bed mobility and locomotion on and off unit. Has Right bka ([MEDICAL CONDITION]) and wear (wears) a prosthetic leg. She uses walker at time (times) and wheelchair for mobility" was identified as a problem on 11/19/10. The goal and target date was "Elder will maintain current level of functioning with her adl (Activities of Daily Living) carte (care) through 8/11/12". Record review for this resident revealed that there were Psychiatric Evaluations dated 1/20/11 and 1/31/11 for Depression. Record review revealed the following documentation of behaviors for Resident #2: 4/24/11 at 11:00 a.m. Nurse's Notes "Staff reported to this writer that Elder ... (Resident #2) who was previously moved from room [ROOM NUMBER], continues to go to that room. The staff observed ... (Resident #2) talking rudely to Elder ... (Resident A) Staff state that prior shift reported ... (Resident #2) was in room [ROOM NUMBER] at 6:30 this a.m. The reason for ...(Resident #2) frequent visits to the room with ... (Resident A) Is subject to speculation, due to ... (Resident #2) reportedly negative attitude toward ... (Resident A) ..(Resident#2) was informed that she could visit with ... (Resident B) and she should be polite to ... (Resident A), as that is ...(Resident A) room and (She) ... (Resident #2) has moved to another room .... (Resident #2) verbalized understanding of this recommendation." 5/18/12 Psychoactive Medication Quarterly Evaluation "Behavior warranting use of medication-Verbal abusive roommates.." 6/9/12 Psychoactive Medication Quarterly Evaluation "Behavior warranting use of medication- verbal abuse ..." 6/11/12 at 8:25 p.m. Nurse's Notes documented "went to Elders room and her roommate ...fussing and cussing at each other because ... (roommate) turned the wrong T.V. off. Elders finally calmed down p (after) about 15 minutes." 6/13/12 at 8:45 p.m. Nurse's Notes documented "Roommate had taken a pack of her noodle when she found out she started to talking loud saying she was going to beat roommate MF ass, beat the breaks off her if she put her hands on anything of hers she was going to burst her head open ..." 6/14/12 at 10:58 p.m. Nurse' s Notes "... altercation with another resident earlier during shift, became physically aggressive, redirection given, other resident removed from room ..." 6/21/12 at 5:30 p.m. Nurse's Notes "Argumentative and verbally abusive toward other elders ..." 6/15/12 Certified Nurse Practitioner note, revealed "This past week ... (Resident #2) and another resident had a physical altercation - No injury reported - Other resident currently in hospital for eval (evaluation) of behaviors and medication management. Plan to monitor behavior and make adjustments as needed." Interview on 8/23/12 at 12:45 p.m. with the facility Administrator and Director of Nursing (DON) revealed that there was no monitoring of behaviors of resident on resident incidents for Resident #2 and no care plan to address the problem of resident on resident behaviors for Resident #2. Resident #3 and #4 Record review for Resident #3 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment with the Assessment Reference Date of 8/1/12 revealed that the resident's Cognitive Skills for Daily Decision Making was coded as " Severely Impaired " . Observation on 8/23/12 at 4:00 p.m. of Resident #3 revealed that he was a tall, thin man wheeling in the hallway in his wheelchair. Review of the 8/11/12 at 4:30 p.m. Nurse's Notes for Resident #4 with whom Resident #3 had the altercation revealed "Was in DR (dining room) when an elder (initials of Resident #3) propelled himself and w/c (wheelchair) to his supper table. This elder informed (initials of Resident #3) to leave the table, he wasn't feeling well, (initials of Resident #3) did not leave. This elder repeated to (initials of Resident #3) to leave he wasn't feeling well, he then pushed (initials of Resident #3) to another table. (Initials of Resident #3) came back and they were fussing then started hitting each other. Was separated per staff (initials of staff) she got (initials of Resident #3) and put him @ (at) another table. No apparent injuries from either one. Both were told not to behave in that manner ... " Review of the Nurse's Notes for 8/11/12 at 8:45 p.m. for Resident #3 revealed that "Nurse from other unit reported to writer that resident propelled himself to resident from her unit (and) had an incident with words exchange followed by resident (s) hitting each other. MD (medical doctor) notified per (name of Licensed Practical Nurse). No apparent injury ... " Interview on 8/23/12 at 4:40 p.m. with the Administrator of the facility revealed that a resident on resident altercation was considered abuse. The administrator stated there was no documented investigation concerning the incident and there had been no reports made to the appropriate state agencies. The facility policy in the "Prevention" section, stated that "residents with needs/behaviors that could lead to conflict or neglect, (i.e. (that is) residents having a history of aggressive, hostile, self injurious behavior; residents who are prone to wander into other resident's rooms; residents with a communication disorder and those who have need of acute or totally dependent nursing care)" are to be assessed, care planned and monitored. The "Investigation" section of the policy stated "(Name of Facility) will identify and investigate all incidents, including the staff member responsible for reporting. An investigation of any alleged violation will be conducted and this facility will give an account of the findings to the proper authorities." Review of information provided by the facility as evidence of an in-service conducted on 8/8/12 and 8/9/12 revealed the following: In the "Abuse Policy Among Residents" section it was stated that "It is a policy of (Name of Facility) that if any resident who is determined to be of sound mind hit another resident, he or she will be discharged promptly. Procedure: 1. (Name of Facility) will investigate the alleged abuse of one resident against another. 2. All abuse of one resident against another resident will be reported to the Complaint Division, Licensure and Certification. (Phone Number of the Complaint Division) 3. A Written report will be made within 72 hours of the incident. An oral or telephoned report will be made within 24 hours of the incident."