Every finding on record at Countryside Post-Acute and Rehabilitation Center

Based on policy review, Infection Control Nurse job description review, facility Infection Control Program document review, Instructions for Humalog sheets review, medical record review, observation, and interview, the facility failed to establish and implement a program to identify, report, investigate, and control infections and communicable diseases when the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) failed to track organisms being treated in the facility, monitor for outbreaks and cross contamination, and when 1 of 3 staff ( Licensed Practical Nurse (LPN) B) failed to properly clean an insulin pen during medication administration. This had the potential to affect 88 of 88 residents in the facility. The findings include: 1. Review of the facility policy titled, 'Infection Prevention and Control Program, dated 6/20/2025, revealed .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The designated Infection Preventionist is responsible for the oversight of the program and serves as a consultant to our staff on infectious diseases.surveillance, and epidemiological investigations of exposures of infectious diseases.Surveillance: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff. Review of the undated facility policy titled, Infection Surveillance, revealed .purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.Data to be collected, including how often and the type of data to be documented, including: The infection site, pathogen.The facility will communicate to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical intervention as indicated .All resident and infections will be tracked. Review of the undated facility policy titled, Insulin Pen, revealed It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing.Procedure.Gather supplies needed . Perform hand hygiene .Don gloves .Remove the pen cap from the insulin pen.Wipe the rubber seal with an alcohol pad.Screw the pen needle onto the insulin pen. Review of the INSTRUCTIONS FOR USE HUMALOG.KwikPen.insulin lispro. revealed .Pull the Pen Cap straight off .Wipe the rubber seal with an alcohol swab .Check the liquid in the Pen .Select a new Needle.Prime before each injection . 2. Review of the Infection Control Nurse job description dated 4/1/2025, revealed .The primary purpose of your job position is to plan, organize, develop, coordinate, and direct our infection control program and its activities in accordance with federal state and local standards guidelines, and regulations that govern such programs, as may be directed by the Administrator.Maintain computerized infection control tracking and trending logs.for all facility infections. 3. Review of the facility's infection tracking report dated 12/2025, revealed a total of 29 resident infections and only 4 of the 29 infections were tracked by organism. Review of the facility's infection tracking report dated 1/2026, revealed a total of 29 resident infections and only 5 of the 29 infections were tracked by organism. Review of the facility's infection tracking report dated 2/2026, revealed a total of 23 resident infections and only 1 of the 23 infections was tracked by organism. During an interview on 2/24/2026 at 3:31 PM, the Infection Control Nurse (ICN) was asked should you track resident infections by organism. The ICN stated, Yes. The ICN was asked where do you track resident infections. The ICN stated, On a spreadsheet but it's not consistent, there are blanks on those reports. The ICN was asked should all resident infections be tracked by organism for accurate monitoring and tracking and trending. The ICN stated, Yes, the organism should be on there. 4. Observation and interview during medication administration, at the [NAME] medication cart, on 2/24/2026 at 11:11 AM, revealed LPN B removed an insulin pen and supplies from the drawer of the medication cart, performed hand hygiene, donned gloves, removed the cap from the insulin pen, and twisted a needle onto the pen. LPN B failed to clean the rubber seal of the insulin pen with an alcohol pad before twisting on the needle. LPN B entered Resident #80's room and administered the ordered dose of insulin. LPN B removed the needle from the insulin pen and placed it in the sharp's container, removed gloves, performed hand hygiene, and returned to the medication cart. LPN B placed the cap back on the insulin pen and placed the insulin pen back in the drawer of the medication cart. LPN B failed to clean the insulin's rubber seal with an alcohol pad before putting the cap back on. LPN B was asked what should be done before capping the insulin pen with the needle and before placing the top back on the insulin pen after use. LPN B stated, I do not know .I will find out. LPN B walked away from the [NAME] medication cart and returned. LPN B stated, .before recapping, need to clean with alcohol, and I failed to clean with the alcohol pad before placing the cap on . During an interview on 2/25/2026 at 11:31 AM, the Director of Nursing (DON) was asked during use of the insulin pen when should staff clean or disinfect the rubber seal. The DON stated, Prior to placing the needle on the insulin pen and after each use.

Based on policy review, medical record review, observation, and interview, the facility failed to provide dental services for 1 of 3 (Resident #17) sampled residents reviewed for dental services. The findings include: 1. Review of the facility undated policy titled, Dental Services, revealed .It is the policy of this facility to assist residents in obtaining routine .and emergency dental care .'Routine dental services' means an annual inspection of the oral cavity for signs of disease .smoothing of broken teeth .'Emergency dental services' includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist .The Social Services Director maintains contact information for providers of dental services that are available to the facility residents .The facility will if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from dental services location. 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, and Hypertension. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #17 scored a 15 on the Brief Interview for Mental Status assessment (BIMS), which indicated she was cognitively intact. The resident had no broken teeth and no mouth or facial pain, discomfort, or difficulty chewing. Review of the medical record revealed Resident #17 received services from (named) dental provider #2 on 5/20/2025 and 6/26/2025 and needed 2 teeth to be extracted. Review of the (Named) dental provider #2 progress note dated 7/10/2025, revealed .Pt [Patient] had extractions today. Monitor Pt. x [times] 24 [hours].Surgical Extraction.Quantity 2. The facility was unable to provide any documentation of dental services after 7/10/2025. During an interview on 2/23/2026 at 10:40 AM, Resident #17 was asked if she received dental care at the facility. Resident #17 confirmed she had teeth extracted by a dental provider but had what she described as half a tooth left and the provider has not returned to extract the other half of the tooth. Resident #17 was asked did the facility say why the dentist did not come back. Resident #17 stated No one here has told me. The tooth has a sharp point that needs to come out.it rubs my tongue. During a cell phone interview on 2/24/2026 at 2:26 PM, Resident #17's daughter was asked to tell this surveyor about the resident's dental concerns. Resident #17's daughter stated, . My mother has not seen the dentist since July 2025. I called the social worker to see why my mother has not seen the dentist and [Resident #17] needs a tooth extracted [pulled]. The last dentist [named dental provider #2] said that they needed to return to pull another tooth. When I called the facility, I spoke with social service at the facility .The social service worker never called me back. Resident #17's daughter was asked if she was given a reason why the dentist had not returned for the tooth extraction. Resident #17's daughter stated, The social worker has not gotten back to me, but my mother's tooth needs to be pulled . Resident #17's daughter stated the problem with her [Resident #17] tooth made it difficult for her mother to eat. During an interview on 2/25/2026 at 8:40 AM, the Social Service Director (SSD) confirmed that there is a dental service that comes onsite to give dental care to residents. The SSD was asked who is responsible for making sure the residents are seen by a dentist. The SSD stated, That is me . The SSD was asked how do you ensure every resident is seen by a dentist. The SSD stated, By the staff, or the residents let me know if an issue, then I reach out to dental or the NP [Nurse Practitioner]. The SSD confirmed residents should be seen twice a year by dental services. The SSD was asked if she had spoken with Resident #17's daughter. The SSD stated, Yes, she [Resident #17's daughter] mentioned to me that Resident #17 had a piece of tooth in her gum and wanted to be seen by the dentist.this conversation was the end of January 2026 [the SSD was not able to give a day in January 2026] . The SSD was asked if she notified [named dental provider #2] of the daughter's request. The SSD stated, No. The SSD was asked what should have been done when you were notified in January that Resident #17 had a piece of tooth that needed to be removed and had requested to see the dentist. The SSD stated, I should have either worked on getting Resident #17 out to a local dentist or see if [named dental provider #2] would do an emergency visit. The SSD was asked when did [named dental provider #2]'s contract end. The SSD stated, When a contract was signed with [named dental provider #1] in February. I reached out to [named dental provider #1] yesterday [2/24/2026] . The SSD was asked when was the first time you reached out to [named dental provider #1] to see when they were coming. The SSD stated, .when you asked me [2/24/2026] about her [Resident #17's] dental visits. The facility failed to ensure Resident #17 received promptly needed dental assistance when neither (named) dental services #2, nor (named) dental services #1, were notified of Resident #17's dental problem and request she be seen and no attempt was made to seek outside services if neither dental provider was available. During an interview on 2/25/2026 at 11:26 AM, the Director of Nursing (DON) was asked if a resident needed a tooth extracted and the facility was notified by the family that the resident needed a tooth extracted what did she expect staff to do. The DON stated, Notify the NP to see if anything she [the NP] needed to address and notify dental [a dental provider] to see if they [a dental provider] could come in the facility .I would start at Social Services notifying dental to see if they could come in and see the resident. The DON was asked how soon dental should be notified by Social Services. The DON stated, I would think when notified by the family.I would expect staff to reach out to dentist the day of or the day after the notification.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by expired food items in the cooler, 1 of 5 Kitchen staff (Cook #1) failed to practice infection control while performing tray line temperatures, and 2 of 3 (West and East Hall) nourishment refrigerators were dirty. This had the potential to affect 75 of 85 residents who had received a tray from the Kitchen. The findings include: Review of the facility's undated policy titled, Getting Ready to Take Food Temperatures Sanitizing The Thermometer, revealed .The thermometer must be first sanitized and calibrated .The thermometer must be sanitized to avoid contaminating the food being tested .wipe the stem of the thermometer with an alcohol swab between measurements . Observation of the walk in cooler in the Kitchen on [DATE] beginning at 9:30 AM, revealed 8 of 15 quarts of Scrambled Egg Mix with an expiration date of [DATE]. Observation of the walk in cooler in the Kitchen on [DATE] at 7:50 AM, revealed a new case of 14 quarts (1 quart had been used) of Scramble Egg Mix with an expiration date of [DATE]. During an interview on [DATE] at 7:50 AM, the Certified Dietary Manager (CDM) stated, .the 8 quarts from yesterday and 1 quart from today's case was used to make scrambled eggs for the residents this morning .Those quarts were not rotated out, it was my responsibility . The CDM confirmed the expiration date of [DATE] and the expired cartons were disposed of. Observation in the Kitchen on [DATE] at 11:27 AM, revealed Cook #1 taking temperatures along the tray line prior to lunch. She wiped the digital thermometer off with a paper towel, placed the thermometer into a glass of ice water to calibrate, then placed the thermometer into the turkey and wrote the temperature down. She then wiped the thermometer off with the same paper towel, placed the thermometer into a glass of ice water, then placed the thermometer into the gravy and wrote the temperature down. She then wiped the thermometer off with the same paper towel she had previously used to clean the thermometer with after taking the turkey's temperature. The cook proceeded this process until the temperature of all 14 food items had been taken. During an interview on [DATE] at 11:45 AM, the CDM was asked to observe her cook and tell this writer if she saw anything wrong with the procedure her cook was using for taking the temperatures. The CDM stated, .she is using the same paper towel to wipe the thermometer off each time she removes the thermometer from a food item . The CDM then proceeded to the kitchen sink and pulled several paper towels and gave them to the cook. The CDM was asked if that was the appropriate way to disinfect the thermometer to prevent cross contamination. The CDM stated, .we've always used paper towels . The CDM was asked if she ever used alcohol wipes. The CDM stated, .we don't have any . Observation of the West Hall nourishment refrigerator on [DATE] at 2:30 AM, revealed unknown spilled substances in the drawers and on the shelves. Observation of the East Hall nourishment refrigerator on [DATE] at 6:45 PM, revealed unknown spilled substances in the drawers and on the shelves. Interview with the Regional Nurse on [DATE] at 6:48 PM, stated, .this sure needs to be cleaned .

Based on facility policy, COVID 19 testing log review, and staff interview, the facility failed to develop and implement a system to track and ensure all staff were tested for COVID-19 twice weekly for the prevention and potential spread of COVID 19 when 29 of 42 staff members (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #2, #3, #4, #7, and #8, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, and #14, Occupational Therapist (OT) #1 and #2, Physical Therapist Assistant (LPT) #1, Housekeeper #1, #2, and #3, Certified Dietary Manager (CDM), Receptionist #1, and Cook #1 and #2) failed to perform COVID 19 testing for 6 days of 18 days (8/23/2021, 8/26/2021, 8/30/2021, 9/2/2021, 9/6/2021, and 9/9/2021) reviewed. The findings include: Review of the facility's policy titled Covid Guidance . dated 4/27/2021, revealed .TESTING: Unvaccinated staff must continue to be routinely tested based on county positivity rates .> [greater than] 10% 2 x week [twice a week] . Review of the facility's COVID TESTING logs from 8/23/2021-9/9/2021 revealed the following employees failed to perform the required COVID 19 testing: a. 8/23/2021 - CNA #1, LPN#2, and LPN #3. b. 8/26/2021 - CNA #1 and LPN #2 c. 8/30/2021 - LPN #3, #4, and #5 d. 9/2/2021 - CNA #2 and LPN #4 e. 9/6/2021 - CNA #1, #2, #4, #5, #6, #7, #8, #9, #10, and #11, LPN #7 and #8, RN #1, the CDM, Housekeeper #1 and #2, OT #1 and #2, PTA #1, and Cook #1. f. 9/9/2021 - CNA #5, #8, #9, #10, #11, and #13, LPN #2, #3, #4, #7, and #8, Receptionist #1, Cook #2, and Housekeeper #3. During an interview on 9/10/2021 at 10:30 AM, the Administrator was asked about the blank spaces on the testing log and what the blank spaces meant. The Administrator stated, .That's a good question. The Administrator was asked if any staff member was making sure the staff tested prior to working. The Administrator stated, I don't know. During an interview on 9/10/2021 at 2:40 PM, the Administrator stated, .there are 48 total employees that should test on testing dates .they [staff] get busy and forget .they will be re-educated on the importance of testing . The Administrator was asked if the staff should be tested twice weekly. The Administrator stated, Absolutely.

Based on medical record review and interview, the facility failed to ensure a Physician's Order was obtained related to Hospice for 1 of 1 sampled resident (Resident #21) reviewed for hospice. The findings include: Review of a medical record, revealed Resident #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #21 was receiving hospice but there was no Physician Order or Care Plan for hospice. During an interview on 9/10/2021 at 10:10 AM, the Regional Consultant stated, No, she [Resident #21] didn't initially have an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 nurses (Licensed Practical Nurse (LPN) #7) followed the facility policy for medication administration through a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #24) observed receiving medications through a PEG tube. The findings include: Review of the facility's policy titled Administering Medications through an Enteral Tube, revised 11/2018, revealed .Dilute medication . Dilute crushed (powdered) medication with at least 30 ml [milliliters] purified water (or prescribed amount) .pour diluted medications into the barrel of the syringe . Review of the medical record, revealed Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Flush peg tube with 100cc [cubic centimeter] of water every shift to keep tube patent . Observation in the resident's room on 9/8/2021 at 10:57 AM, revealed LPN #7 administered the dry, crushed medications to Resident #24 without diluting with water and administered each medication individually, dry into the barrel of the syringe. LPN #7 followed each medication with 5 ml of water poured into the barrel of the syringe. The last medication clogged up in the syringe. Then LPN #7 reconnected the syringe to the PEG and used the plunger to push the medication through the PEG tube. During an interview on 9/8/2021 at 6:10 PM, LPN #7 confirmed she administered medications without diluting them with water. During an interview on 9/10/2021 at 4:55 PM, the Regional Consultant confirmed that dry, crushed medications administered through a PEG tube should be diluted before administration.

Based on the policy review, medical record review, observation, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status, and failed to accurately assess, implement, and monitor interventions to prevent severe weight loss for 1 of 4 sampled residents (Resident #22) for weight loss. The findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised 9/2008, revealed .nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter .weights will be measured monthly .dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time .threshold for significant unplanned and undesired weight loss will be based on the following criteria .3 months - 7.5% weight loss is significant; greater than 7.5% is severe . Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had severe cognitive impairment and required total assistance with activities of daily living. Review of the undated Care Plan revealed, .Potential for weight concerns/at risk for malnutrition .Monitor/record/report to MD [medical doctor] PRN [as needed] s/sx [signs/symptoms] of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs [pounds] in 1 week, > [greater than] 5% [percent] in 1 month, >7.5% in 3 months, >10% in 6 months .RD [Registered Dietitian] to evaluate and make diet change recommendations . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weights revealed the following: a. 5/12/2021 228.8 lbs b. 8/5/2021 193.8 lbs (which is significant weight loss of 15.30% in 3 months) c. 9/8/2021 210.2 lbs The facility failed to follow the policy when they did not obtain resident weights on admission or weekly for two weeks after admission. During an interview on 9/9/2021 at 2:48 PM, the Nurse Practitioner stated, .We got a new dietitian a month ago .a new DON [Director of Nursing] .something was going on with the Restorative technician that did the weights .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents (Resident #338) reviewed for an indwelling urinary catheter. The findings include: Review of the facility's policy titled Foley Catheter Insertion, Male Resident, revised 10/2010, revealed .Verify that there is a physician's order for this procedure . Review of the medical record, revealed Resident #338 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #338 was cognitively intact, required total dependence for all activities of daily living, and had an indwelling urinary catheter. Review of the Physician Orders dated 8/31/2021, revealed .Foley output two times a day . There was no order for an indwelling urinary catheter. Observation in the resident's room on 9/7/2021 at 10:21 AM, 9/7/2021 at 12:34 PM, 9/7/2021 at 5:25 PM, 9/8/2021 at 9:35 AM, and on 9/8/2021 at 3:51 PM, revealed Resident #338 did have an indwelling urinary catheter. During an interview on 9/10/2021 at 1:55 PM, the Regional Consultant confirmed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on medical record review and interview, the facility failed to implement neurological (neuro) checks and appropriate interventions after unwitnessed falls for 2 of 2 sampled residents (Resident #85 and #86) reviewed for falls. The findings include: Review of the medical record, revealed Resident #85 had diagnoses of Cerebral Infarction, Dysphagia, [CONDITION(S)], Malignant Neoplasm of Lung, History of Covid-19, Depression, Anxiety, Failure to Thrive, and Repeated Falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #85 had severe cognitive deficits, required limited to extensive assistance with most of his activities of daily living, had functional limitations in range of motion with impairment on one side in both his upper and lower extremities, and had 1 fall with no injury and 1 fall with injury. Review of an Incident Investigation Note dated 8/17/2021, revealed .Resident found in floor sitting on his bottom in from [front] of the restroom door. Resident states I was going to the bathroom Resident denies any pain or injury. Resident states It hurt my pride .Resident assessed for injury and assisted back to bed. No injury noted. Patient immediately reoriented and reeducated to room, bathroom, and proper use of call light. Encouraged to request assistance from staff before getting out of bed . During an interview on 9/10/2021 at 8:34 AM, the Director of Nursing (DON) and the Regional Consultant confirmed the interventions were inappropriate for a resident with severe cognitive deficits. Review of an Alert Note dated 8/18/2021, revealed .patient was found in the floor at 1:10 pm [PM] this afternoon lying on his back at the foot of the bed .noted and inch long laceration this nurse cleaned wound and applied dressing to stop the bleeding, contacted md [medical doctor] and received the order to send out to ER [emergency room ] . Review of the medical record, revealed Resident #85 returned from the emergency roiagnom on [DATE], and neuro checks were not performed for 72 hours after Resident #85's fall. During an interview on 9/10/2021 at 8:34 AM, the Director of Nursing (DON) stated, .unwitnessed falls require 72 hour neuro checks . Review of a medical record, revealed Resident #86 had diagnoses of Dementia with Behaviors, Dysphagia, [CONDITION(S)], Mood Disorder, Radiculopathy, Hypertension, and Left Foot Drop. Review of an admission MDS assessment dated [DATE], revealed Resident #86 had severe cognitive deficits, required limited to supervisory assistance with her activities of daily living, and had no functional limitations in range of motion. Review of a Nursing Note dated 5/20/2021, revealed .Found resident sitting on floor near her bed, Resident stated that she did not know how she got on the floor but she needs help to get up. Neuro checks completed and assisted resident to her bed. Obtained vital signs and head to toe assessment completed. Resident has a hematoma to the right side of her head behind and above her ear. A SkinTear to right elbow which was cleaned with wound cleanser and steristrips applied and covered with border gauze . Review of the medical record, revealed no neuro checks were not performed for 72 hours after Resident #86's fall. Review of an Incident Investigation dated 5/24/2021, revealed .Was alerted to resident in floor beside the bed. Was readmitted today from hospital. Resident is alert with confusion .Resident was put back in bed by charge nurse and PT [Physical Therapy]. Head to toe assessment completed. Bed/Chair alarm . Review of the medical record, revealed no neuro checks were not performed for 72 hours after Resident #86's fall. Review of a Nursing Note dated 5/25/2021, revealed .Called to resident's room by her roommate. Resident sitting on the floor facing her bed. Resident stated that she did not know how she got in the floor but she needed help to get up. Head to toe assessment completed and resident assisted by 2 staff members to get up and onto the bed. Vital signs obtained . Review of the medical record, revealed no neuro checks were not performed for 72 hours after Resident #86's fall. Review of a Nursing Note dated 5/27/2021, revealed .Resident found on her stomach by the door of her room after getting out of her bed. Small 1cm [centimeter] skintear found on her left elbow which was cleaned with wound cleanser and cover with border dressing. Resident stated she fell on her bottom and voiced no complaint of pain. Neuro check WNL [within normal limits] for resident . Review of the medical record, revealed no neuro checks were not performed for 72 hours after Resident #86's fall. Review of an Incident Note dated 6/12/2021, revealed .Resident found on left side of bed with her upper torso still on bed and her knees on floor at 11:15pm. This resident BIMS [Brief Interview for Mental Status] is (99). She was assessed and assisted back to bed. Found pink quarter size round areas to front of bil [bilateral] knees. No treatment needed. Neuro initiated. Resident placed in low bed with bed alarm . Review of the medical record, revealed no neuro checks were not performed for 72 hours after Resident #86's fall. During an interview on 9/10/2021 at 10:21 AM, the DON was asked what she expects her staff to do when a resident falls. The DON stated, .I expect the nurse to be notified, the nurse to assess the resident, call the MD, family, and the DON, begin neuro checks, and complete and incident report . During an interview on 9/10/2021 at 11:30 AM, the Administrator and the Regional Consultant confirmed they did not have documentation that the neuro checks were performed for the month of May.

Based on medical record review and interview, the facility failed to initiate a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were ordered for 1 of 21 sampled residents (Resident #12) reviewed. The findings include: Review of the medical record, revealed resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a medical record, revealed there was no significant change MDS assessment completed after Resident #12's admission to hospice services. Interview on 9/9/2021 at 3:20 PM, the MDS Coordinator was asked if a significant change should have been completed when Resident #12 was ordered hospice services. The MDS Coordinator stated, .I didn't do it .

Based on policy review, observation, and interview, the facility failed to promote and enhance the resident's dignity during a dressing change for 1 of 3 sampled residents (Resident #338) reviewed. The findings include: Review of the facility's policy titled Quality of Life- Dignity, revised 2/2020, revealed .Staff promote, maintain, and protect resident privacy, including bodily during assistance with personal care and during treatment procedures . Review of the medical record, revealed Resident #338 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #338 was cognitively intact and required total dependence with all activities of daily living. Wound care observation in the resident's room on 9/9/2021 at 3:08 PM, revealed the Treatment Nurse and Licensed Practical Nurse (LPN) #1 left Resident #338 exposed on the bed during pressure injury treatment and when leaving the room, left the door open. The resident was turned on his side with his posterior exposed. During an interview on 9/9/2021 at 7:05 PM, the Treatment Nurse was asked if the resident should have been covered up during pressure injury treatment and before leaving the room, with the door left open. The Treatment Nurse stated, .I didn't even realize he was not covered. He should have been .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, Labor Detail Reports, Employee/Visitor/Vendor Check-In logs, staffing schedules, and interview, the facility failed to follow CDC infection control guidelines to properly prevent and/or contain COVID-19 when 68 of 114 staff members (Cook #1, #2, #3, #4, #5, #6 and #7, Registered Nurse (RN) #1, #2 and #3, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 #14 and #15, the Social Worker, Housekeeper #1, #2, #3, #4, #5, #6 and #7, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21 and #22, Restorative Aide #1, #2, and #3, the Director of Recreation, the Physical Therapy Assistant (PTA), the Physical Therapist (PT), Maintenance Laborer #1, Maintenance Director #1 and #2, the Occupational Therapist (OT), the Occupational Therapy Assistant (OTA), Dietary Aide #1, the Speech Therapist (ST) and the Housekeeping Supervisor) failed to complete screenings for COVID 19 prior to working for 52 of 57 days (3/17/2021-3/31/2021, 4/1/2021-4/24/2021, 4/30/2021, and 5/1/2021-5/12/2021) reviewed. This had the potential to affect the 72 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) website document titled, .Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [Coronavirus Disease] Spread in Nursing Homes, updated 3/29/2021, revealed .This guidance summarizes the core infection prevention and control practices for nursing homes during the [CONDITION(S)]-CoV-2 pandemic .Establish a process to ensure HCP [Healthcare Personnel] (including .ancillary staff such as environmental and dietary services) entering the facility are assessed for symptoms of COVID-19 . Review of the Labor Detail Reports and EMPLOYEE/VISITOR/VENDOR CHECK-IN logs from 3/17/2021-5/12/2021 revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 3/17/2021-Cook #1, RN #1, and LPN #1. b. 3/18/2021-LPN #2, the Social Worker, and RN #1. c. 3/19/2021-LPN #3. d. 3/20/2021-Housekeeper #1, LPN #1, and LPN #4. e. 3/21/2021-LPN #4 and #5, CNA #1 and #2, and Restorative Aide #1. f. 3/22/2021-LPN #1 and #4, CNA #3, and the Director of Recreation. g. 3/23/2021-LPN #5 and #6, CNA #1 and #4, the Director of Recreation, and the PTA. h. 3/24/2021-LPN #1 and #5, Housekeeper #2, CNA #5, #6, #7, and #8, the PT, and Maintenance Laborer #1. i. 3/25/2021- LPN #5 and #6, and CNA #1 and #9. j. 3/26/2021-LPN #7, and CNA #6 and #9. k. 3/27/2021-Cook #1, #2, and #3, LPN #5, #6 and #7, Maintenance Director #1, and the OT. l. 3/28/2021-Cook #1, #2, and #3, and CNA #7 and #10. m. 3/29/2021-RN #2, LPN #6, Housekeeper #1, CNA #1, and Restorative Aide #2. n. 3/30/2021-Cook #2 and #4, RN #2, LPN #8, and the OTA. o. 3/31/2021-RN #1 and #2, LPN #1, CNA #6 and #11 and Restorative Aide #2. p. 4/1/2021-RN #2, LPN #2 and #9, CNA #1, #4, #6, #8, and #9, the Director of Recreation, and Maintenance Laborer #1. q. 4/2/2021-Cook #2, RN #2, LPN #3, #4, and #5, Housekeeper #3, CNA #3, #8, and #9, and Maintenance Laborer #1. r. 4/3/2021-Cook #3, RN #1 and #2, LPN #4, #5, and #10, Housekeeper #1, CNA #2, Dietary Aide #1, and the ST. s. 4/4/2021-Cook #5, RN #2, LPN #4, #5, and #10, Housekeeper #2, and CNA #2 and #8. t. 4/5/2021-RN #1 and #2, LPN #4, and CNA #4. u. 4/6/2021-RN #2. v. 4/7/2021-Cook #2, Housekeeper #2, CNA #1 and #12, and the Director of Recreation, and Maintenance Laborer #1. w. 4/8/2021-Cook #4, LPN #4 and #10, CNA #1, 9, #14 and #15, Restorative Aide #2, and the Director of Recreation. x. 4/9/2021-Cook #4, CNA #9, #12, and #13, Restorative Aide #2, and the Director of Recreation. y. 4/10/2021-Housekeeper #2 and CNA #1, #2, and #12. z. 4/11/2021-Cook #2 and #4, LPN #5 and CNA #2, #8, #16 and #17. aa. 4/12/2021-Cook #2, LPN #5, Housekeeper #2, CNA #1, and the Director of Recreation. bb. 4/13/2021-Cook #6, LPN #4, #5, and #9, Housekeeper #4, CNA #1 and #17, Restorative Aide #1, and the Director of Recreation. cc. 4/14/2021-Cook #4, CNA #15, and Restorative Aide #2. dd. 4/15/2021-Cook #2, LPN #5, CNA #1, and the Director of Recreation. ee. 4/16/2021-Cook #2 and #3, LPN #5, CNA #7 and #8, the Director of Recreation, and Maintenance Laborer #1. ff. 4/17/2021-Cook #1 and #2, LPN #4, #5, #9, #10 and #11, Housekeeper #2, CNA #2, #4, #6, and #16, the Director of Recreation, Maintenance Laborer #1, and the OT. gg. 4/18/2021-Cook #2, LPN #10, Housekeeper #2, and CNA #2 and #8. hh. 4/19/2021-Cook #2 and #3, LPN #4, Housekeeper #1, CNA #5, #9, #11 and #17, Restorative Aide #3, the Director of Recreation, and Maintenance Laborer #1. ii. 4/20/2021-Cook #2 and #4, LPN #10, CNA #11, #12 and #17, the Director of Recreation, and Maintenance Laborer #1. jj. 4/21/2021-Cook #2 and #7, LPN #10, the Social Worker, CNA #4, #9 and #22, and the Director of Recreation. kk. 4/22/2021-LPN #10 and #15, the Social Worker, CNA #1, #8 and #15, the Director of Recreation, and the ST. ll. 4/23/2021-Cook #4, LPN #4, #5, #8, #10, and #15, CNA #2, #9, #13, #16, and #18, the Director of Recreation, and Dietary Aide #1. mm. 4/24/2021-Cook #3, LPN #2, Housekeeper #5, CNA #1, #2, #11, #17 and #18, the Director of Recreation, and Maintenance Director #2. nn. 4/30/2021-Cook #2 and #4, LPN #3 and #10, the Social Worker, CNA #2, #8, and #21, and Maintenance Director #2. oo. 5/1/2021-Cook #6, CNA #2, and LPN #5. pp. 5/2/2021-Cook #6, LPN #5 and #9, CNA #2, #9 and #12, and the Housekeeping Supervisor. qq. 5/3/2021-Housekeeper #1 and CNA #15. rr. 5/4/2021-Housekeeper #1 and #3, LPN #10 and #15, CNA #9, and Maintenance Director #2. ss. 5/5/2021-RN #2, LPN #4, and CNA #1. tt. 5/6/2021-RN #2. uu. 5/7/2021-LPN #14, the Social Worker, CNA #13 and #18, the Director of Recreation, and Maintenance Director #2. vv. 5/8/2021-RN #2, LPN #13, CNA #1 and #17, and the Housekeeping Supervisor. ww. 5/9/2021-Cook #4, RN #2, LPN #9, #10, #12, and #13, CNA #7, #8, #12 and #20, and the Housekeeping Supervisor. xx. 5/10/2021-LPN #13, Housekeeper #1, CNA #1, #7, #9, and #15, and the Director of Recreation. yy. 5/11/2021-RN #3, Housekeeper #6, and CNA #1, #13, and #17. zz. 5/12/2021-LPN #13, Housekeeper #7, the Director of Recreation, and Maintenance Director #2. The facility was unable to provide in-services related to screening procedures prior to 5/13/2021. During an interview on 5/13/2021 at 12:00 PM, CNA #8 confirmed staff should check their temperature, answer screening questions and sign in when arriving to work. During an interview on 5/13/2021 at 12:57 PM, the Unit Manager/Infection Control Nurse confirmed staff should check their temperature and answer screening questions when arriving to work. During an interview on 5/13/2021 at 2:30 PM, CNA #4 confirmed staff should check their temperature and answer screening questions when arriving to work. During an interview on 5/13/21 at 4:30 PM, the Interim Director of Nursing confirmed the facility should follow CDC guidelines for screening employees. During an interview on 5/13/2021 at 5:15 PM, the Receptionist was asked if anyone audited the screening logs to ensure the staff were screening in. The Receptionist stated, I was trying to audit it, but people like our regional nurse .would show up [on the Labor Detail Report] because they worked remotely .Now people on that [the Labor Detail Report] list are actually people who are in the building . The Receptionist confirmed Cook #6, CNA #2 and LPN #5 worked on 5/1/2021 but were not on the EMPLOYEE/VISITOR/VENDOR CHECK-IN logs. During a telephone interview on 5/13/2021 at 5:18 PM, LPN #3 confirmed staff should check their temperature and answer screening questions when entering the building.

Based on policy review, medical record review, facility investigation, Weather Service Website, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to a cognitively impaired resident with exit seeking behavior for 1 of 3 sampled residents (Resident #1) reviewed for wandering and elopement. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide adequate supervision when Resident #1 exited the facility by crawling through a window, traveled across the facility lawn, up a 4 foot embankment onto a 2 lane highway and was located in a rock lined ditch approximately 585 feet from the facility. The resident was missing from the facility for approximately 20 minutes and sustained multiple abrasions. The recorded temperature was 49 degrees Fahrenheit. Nine days later, the same resident exited the building through a window on the Secure Unit hall, crossed a gravel drive, traveled up a slight incline into a field that was approximately 209 feet from the facility. The resident was missing from the facility for approximately 5-10 minutes and sustained a new abrasion to his right elbow. The recorded temperature was 53 degrees Fahrenheit. The Administrator and the Director of Nursing (DON) were notified of the IJ on 1/22/2021 at 4:17 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 1/5/2021 through 1/26/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 1/23/2021 at 6:30 PM, and was validated onsite by the surveyors on 1/24/2021-1/27/2021 through interviews, review of the Ad hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheet, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, showed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering . Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS/GENERAL, showed, .All unusual occurrences or incidents will result in the Medical Director being notified .Accidents or incidents involving a resident shall be charted in the medical record .All details are to be recorded in the nurses' notes, including disposition and follow up care for a period of seventy-two (72) hours . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurses' Note dated 12/24/2020, showed, .Resident is alert with confusion present .Wanders aimlessly through hallways difficult to redirect at times . Review of a Behavior Note dated 12/25/2020, showed, .Resident is Alert (alert) to person, resident is disoriented to time place and situation, Resident wandered around facility for majority of the shift, resident is unable to be redirected, resident trys (tries) to exit out both doors of the unit . Review of Resident #1's Nurses' Note dated 12/25/2020, showed, .Resident repeatedly tried to exit the facility via (by way of) the fire exit, resident repeatedly tried to exit the covid (COVID) door entrance . Review of a Nursing Wandering Evaluation dated 12/25/2020, showed a score of 12 which indicated the resident was a high risk for wandering and had known history of wandering. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1's Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated the resident had severe cognitive impairment, and exhibited wandering behaviors. Review of a Baseline Care Plan dated 12/29/2020, showed Resident #1 was at risk for elopement with interventions of .Check bracelet for placement each shift .Check functioning of bracelet daily .Keep ID (Identification) and face sheet in wander book .Observe for exit seeking behaviors and patterns . Review of a Nursing Incident Note, dated 1/5/2021, showed, ONE OF THE ON DUTY EMPLOYEE'S WENT AND FOUND PATIENT (Resident #1) ON SIDE OF ROAD AND HE BROUGHT PT (patient) BACK IN BUILDING. HEAD TO TOE ASSESSMENT WAS COMPLETED MULTIPLE SCRATCHES NOTED TO BIL (Bilateral (Both)) ARMS,LEGS, ABDOMEN. NO TREATMENTS REQUIRED . Review of a Nurses' Note dated 1/5/2021, showed, .Noted multiple abrasion (abrasions) on hands and knees areas cleaned .steri-strips (thin adhesive bandage to close wounds) applied to the tip of bi-lat (bilateral) 3rd fingers . Review of an Elopement Incident Report dated 1/5/2021, showed abrasions to the right and left hands and knees and an undescribed injury to the top of the scalp for Resident #1. There was no documentation that Resident #1 fell on this Elopement Incident Report. Review of the Skin Head to Toe Weekly Skin Checks assessment dated [DATE], showed an unmeasured bruise to the right trochanter (upper part of the thigh), and unmeasured abrasions to the right and left knees and the face. Review of the facility's investigation of Resident #1's elopement on 1/5/2021, showed a witness statement dated 1/5/2021, from Certified Nursing Assistant (CNA) #3, that documented, .we helped the patient up from the ditch. His back was wet and dirty due to the fall and seemed to be bleeding from his nose . Review of this investigation showed multiple interviews from staff, an in-service on wandering and elopement dated 1/6/2021, which only had 21 of the 86 facility employees listed as having received the in-service, a Performance Improvement Project, and Resident #1 being moved to the Secure Unit on 1/5/2021 after the elopement. Review of a facility document titled, PIP (Performance Improvement Project): Resident Elopement, dated 1/6/2021, showed, .Social Services to complete elopement assessments on all residents in the facility. Risk assessments to be completed by nursing on all residents in the facility .Education to be completed with nursing concerning completing incident reports, documenting on the 24 hour report and notifying nursing management by 01/15/21 (2021) .Risk Team to discuss weekly and ensure that risk assessments and elopement assessments are completed on admission, with a change in status, and quarterly . The facility was unable to provide any wandering, elopement, or fall risk assessments documented for Resident #1 after the incident on 1/5/2021. Review of the Nurses' Notes dated 1/6/2021-1/8/2021, showed no documentation of measurements of the injuries sustained by Resident #1 during the elopement or any monitoring for additional injuries from the fall on 1/5/2021. Review of a Nurse Practitioner Progress Note dated 1/6/2021, showed, .one of the staff members (Certified Nursing Assistant (CNA) #4) drove in his car down the road (on 1/5/2021) and found (Named Resident #1) lying on the ground and stated he had fallen . Review of a Behavior Note dated 1/8/2021, showed, .resident (Resident #1) is in a manic state, trying to elope, trying to open the window with a fork, removed all sharps to ensure safety. Resident is pushing staff, redirected resident to the activity area . Review of a Behavior Note dated 1/14/2021, showed, .Resident (Resident #1) eloped at about 10:45 am (AM), resident broke out (exited through) another resident window, and crawled out the window. Resident kept asking staff to help him find his keys so he can get his car and go to (Named Store). Resident was redirected through out (throughout) the morning . Review of an Elopement Incident Report dated 1/14/2021, showed an unmeasured non bloody .scrap (scrape) . on the 5th finger of the left hand. Review of the facility's investigation for the elopement on 1/14/2021, showed multiple interviews from staff, an in-service on wandering and elopement, which did not include all staff as having received the in-service, and Resident #1 used a metal dining utensil to get the window open. During an interview on 1/19/2021 at 10:40 AM, the DON was asked to describe the elopement of Resident #1 on 1/5/2021. The DON stated, He was found to be missing by off duty staff member, she came in the building and said there was a man dressed in black walking down (Named Road) .she asked .(Director of Admissions) if we were missing anyone. (Director of Admissions) immediately called the units asking if we had anyone missing by that description. East wing started looking and thought it was (Resident #1) by the description. All the staff were looking, a CNA found a window .was open and screen had been pushed out He (CNA #4) got in his vehicle and the off duty staff member got in her vehicle. The Resident was found at the first driveway on the left after exiting the facility. Both CNAs assisted him up, he was on the ground and placed him in (CNA #4)'s vehicle .He had scratches on both arms and legs, red area on right hip. He was oriented to himself as usual, off by one day of the week, but knew himself. He stated he was going to (Named Store) .received orders to go to the locked Secure Unit. I moved him there. The DON was asked if the staff were educated on wandering. The DON stated, I don't know if I did since he went to a locked unit. The DON was asked if anything else was implemented besides moving him to the Secure Unit. The DON stated, Yes, maintenance came in .found the window latch was broken and replaced it. I got witness statements .Care planned him to go to unit on wandering . The DON was asked how many times Resident #1 eloped. The DON stated, He got out of the window twice, last time last Friday (1/14/2021) that's when he was sent to psych (Psychiatric) hospital. The DON was asked to describe the second elopement on 1/14/2021. The DON stated, They were passing trays on the unit .He went out another resident's window. He pried (open) the window and busted through the screen. He was taking silverware and prying at the window and we didn't know it. He was going to his wife. The therapist caught him over the property line in the field back here The DON was asked what interventions were put in place related to the second elopement. The DON stated, He was 1 on 1 (staff member with him constantly), implemented plastic silverware on the unit and shutting all resident room doors until he was gone (transferred). Maintenance fixed the window within 5 minutes and checked all the windows. During an interview on 1/19/2021 at 12:29 PM the Director of Maintenance was asked what was implemented after Resident #1's elopement. The Director of Maintenance stated, The first incident. I got called in, the resident went out the window. I live 30 minutes away. I don't remember what time I got here .The window was hanging off the guide .When I got to the window the whole window was off the track hanging and about to fall, the screw was bent over where he had slid the window against it. He ripped the outside storm window, ripped from the middle out . The Director of Maintenance was asked what happened when Resident #1 eloped the second time. The Director of Maintenance stated, It happened when I was here, those windows have a piece on each side that will fold towards you, we took those pieces off and made it where it wouldn't do that, he figured that out and made it where they would fold out, he physically pulled the bottom half of the window completely out, he did the same thing to the screen .we started doing twice daily window checks .close to the second incident that occurred (on 1/14/2021) I was down there (Secure Unit) .he had a piece of plastic fork and trying to take a screw out (of the window). I told my assistant (Maintenance Assistant) we need to start checking these windows . The Director of Maintenance was asked if he notified anyone about Resident #1 attempting to unscrew the window. The Director of Maintenance stated, Yes .the Director of Nursing and the nurse, the nurse actually saw him do it. Observation on 1/19/2021 at 12:54 PM, the Director of Maintenance showed surveyors the window Resident #1 exited on 1/5/2021 and explained how it looked when he saw it that night. The Director of Maintenance stated, .It's a wonder the window didn't fall on him. They had been roofing in this area. Luckily, they had cleaned up outside or it could have been worse and he could have gotten hurt . Observation 1/19/2021 at 1:01 PM, the Director of Maintenance showed surveyors the window Resident #1 exited on 1/14/2021 and described how the resident removed the bottom pane of glass. The Director of Maintenance stated, .we took the buttons off, he put something in the hole and triggered the mechanism . Observation on 1/19/2021 at 3:48 PM in front of the facility window that Resident #1 exited from on the second elopement attempt, with Physical Therapist (PT) #1 and the DON, PT#1 used a rolling measuring device to measure the distance Resident #1 had walked from the facility after climbing out of the window on 1/14/2021. Measuring from the window Resident #1 exited, staff and the surveyor walked across a gravel drive, passed a dumpster, and up a slight incline into a field, approximately 209 feet from the facility. PT #1 confirmed that she had seen him through the window at approximately 190 feet, and Resident #1 had walked approximately 209 feet when she reached him. Observation on 1/19/2021 at 3:54 PM in front of the facility window that Resident #1 exited from on the first elopement, with PT #1 and the DON, PT #1 used a rolling measuring device to measure the distance Resident #1 had walked from the facility after climbing out of the window on 1/5/2021. Beginning at the window Resident #1 exited, staff and the surveyor walked across the lawn, up an approximately 4 foot incline, across a 2 lane road, down the side of the road, to a driveway that was built across a rock lined ditch, approximately 585 feet to where staff said Resident #1 was located. During an interview on 1/19/2021 at 4:45 PM, CNA #1 was asked if she provided care to Resident #1 on 1/5/2021. CNA #1 stated, .He wasn't assigned to me but I did help take care of him. The second time he got out he was in my care on the lock down unit (Secure Unit). CNA #1 was asked what Resident #1 was wearing on 1/5/2021, his first elopement. CNA #1 stated, He had on shoes, socks, a long sleeve shirt, a undershirt, and jeans. CNA #1 confirmed that Resident #1 was assigned to her on 1/14/2021. CNA #1 was asked what Resident #1's demeanor was that day. CNA #1 stated, .I caught him in another room trying to unscrew the window with a tool of some sort .Trying to find exits all day long, asking for a door to get out of this place. CNA #1 was asked if this was the same day Resident #1 eloped. CNA #1 stated, Yes .I let the nurse know. CNA #1 was asked if she received any training on wandering residents since the elopements. CNA #1 stated, No, not since the incidents happened. During an interview on 1/20/2021 at 9:55 AM, the Director of Maintenance was asked if he was still conducting window checks twice daily. The Director of Maintenance stated, Yes. I went down there and the nurse said he was trying to get out the window, he had something in his hand, she thought it was a plastic fork .I went in there and saw him looking at a window, he did not have anything in his hand, he was touching the screw. I redirected him, and he went back to his room . The Director of Maintenance was asked if he knew if a room search was initiated for the object. The Director of Maintenance stated, No .from my understanding (CNA #1) .took it away from him . The Director of Maintenance was asked if he had received any in-services on elopements or wandering since Resident #1 had eloped. The Director of Maintenance stated, Not since the elopements .I read over my documents on my own. The Director of Maintenance was asked if he does elopement drills at the facility. The Director of Maintenance stated, Yes .not since the elopement. The Director of Maintenance was asked when the last elopement drill was conducted. The Director of Maintenance stated, A couple of months ago . On 1/20/2021 at 10:15 AM, the Director of Maintenance provided documentation of an elopement drill conducted on 7/10/2020. During a telephone interview on 1/20/2021 at 11:18 AM, CNA #2 was asked about Resident #1's elopement on 1/5/2021. CNA #2 stated, We were working East (Wing) that night, during supper time. I physically took him down there and he sat down on his bed. I set his tray up. I passed a few more trays, I was in the room right next to his to assist a resident .I had seen (saw) him come up the hallway towards the Nurses' Station on East .the last time I saw him (Resident #1) was ambulating in the hallway between 5:30 and 5:50 (PM). The next thing I heard was (CNA #4) yell, 'where is (Named Resident #1)' .he said something about a phone call, I went out to the parking lot, (CNA #4) got in his vehicle. When he returned I was standing in the parking lot, there was traffic going back towards town .He (Resident #1) had an abrasion on bridge of his nose, his nose was bleeding a little, both knees were scraped up, a deeper scrape on his right elbow, scratches on his knuckles and bruises on palms of hands, a spot on his hip .a red spot that looked like it would turn into a bruise. I took him back to his room, but he didn't wanna (want to) stay in his room so he was out in the hallway with us .moved him to Secure Unit. CNA #2 was asked if Resident #1 had a history of [REDACTED].#2 stated, He tried to get out on me one time .(on Sunday 1/3/2021), he tried to get out the fire door . During a telephone interview on 1/20/2021 at 12:27 PM, CNA #3 was asked what she remembered about Resident #1's elopement on 1/5/2021. CNA #3 stated, I was off, I was on my way up there to pick up something. When I passed him on the road he was walking towards traffic on the opposite of the road from (Named Facility). I didn't recognize him .It was dark, he had not made it to the first driveway. When I got to the facility, I told (Director of Admissions) there was a man walking down the road in blue jeans and a dark colored shirt and he was either a drunk or a patient. She then called East Wing and had them check on their patients. I then left the facility to go look for the man. At that time, I didn't know someone was missing. The East Wing was in the middle of supper, the techs (technicians (CNAs) were not aware someone was missing. CNA #3 was asked where Resident #1 was when she located him. CNA #3 stated, He was in the ditch by the first driveway. A car in front of me had stopped and helped get him up. He was on the ground, he had blood on his nose, it looked like carpet burn, like something grazed his nose. He was sitting on the ground in the ditch by the house. I asked him for his name. He said something (Resident #1's last name). I then called (Director of Admissions) and she verified he was a patient. She also told me he was missing, she sent (CNA#4) out to help me. (CNA #4) came in his car and I helped get him (Resident #1) in his (CNA #4) car. During an interview on 1/20/2021 at 12:45 PM, the Director of Admissions was asked what she remembered about Resident #1's elopement. The Director of Admissions stated, I was the manager on duty at the front desk. I called (CNA #3) because I found her cup .She got here a few minutes before 6 (6:00 PM). She jokingly asked 'Are you missing a resident'. She said that there was a gentleman dressed in dark colors and shuffling on (Named Road). So I told her I would call East Wing and check and I asked her to check also .She left and (CNA #4) answered the phone. I asked (CNA #4 ) if he was missing anyone. He replied, 'No.' I said it would be a male in dark clothing. He said 'if it is, it would be (Resident #1)'. I then said, 'Please go check to see if it is because if it is he is walking up (Named Road). About 2 minutes later (CNA #3) called and asked if (Resident #1) was our resident. I said, 'yes.' She said, 'He had fallen in the ditch by the driveway.' I asked if he was ok. She said, 'It's dark and I can't tell, he's bleeding,' someone else had stopped and was there helping .She also asked what they needed to do. I said 'have (CNA #4) bring him back so the nurse could check him out.' I called (Administrator) and let her know and asked what I needed to do. She told me to check every door in the building and have the nurses do a head count of all residents, I paged the DON .By the time I got to East Wing doors they were bringing (Resident #1) in. I checked every door in this building myself. The Director of Admissions asked if anything was paged overhead. The Director of Admissions stated, No .because we were already doing it. The Director of Admissions was asked if the facility was aware of Resident#1's history of wandering before he was admitted . The Director of Admissions stated, Yes, I can't approve (admissions) by myself . The Director of Admissions stated, .He came from psych (psychiatric) unit part of (Named Hospital) . During an interview on 1/20/2021 at 3:48 PM, the DON was asked why an incident report was not completed related to the fall on 1/5/2021. The DON stated, He didn't say he fell .we did an elopement (incident report) . The DON was asked if a fall during an elopement should be documented in the elopement report. The DON stated, Yes . The DON was asked if there was a fall risk assessment completed on Resident #1 on 1/5/2021. The DON stated, I don't see one. During an interview on 1/20/2021 at 4:12 PM, CNA #4 was asked what time Resident #1 eloped on 1/5/2021. CNA #4 stated, When (Named Director of Admissions) called us, we were in the middle of trays (5:45 PM-6:00 PM). I knew who it was when she started describing him. I just went out the door and down the road. CNA #4 was asked where Resident #1 was when he found him. CNA #4 stated, At second driveway on the left standing with one of our employees and another gentleman .you could see some blood through his jeans and a cut on his hand. He was muddy, cold, and wet. He said he was sorry and he was going to get dog food .if (CNA #3) hadn't showed (shown) up the other gentleman was going to take him over to where he lived. CNA #4 was asked if he had been given any in-services on wandering or elopement after this incident. CNA stated, I don't think so. CNA #4 was asked if he had been given any in-services on wandering or elopement after the second elopement on 1/14/2021. CNA #4 stated, I don't believe so. CNA #4 was asked if an elopement drill had been done. CNA #4 stated, No, I've only been back 6 months and we haven't done one . During an interview on 1/21/2021 at 4:37 PM, the Nurse Practitioner (NP) was asked if Resident #1 was an elopement risk when he was admitted . The NP stated Yes. The NP was asked if the facility should have known he was an elopement risk. The NP stated Yes. The NP was asked how she knew Resident #1 had fallen on 1/5/2021. The NP stated, .What I got reported to me was that he was found on the ground and he had said he had fallen. That's what is in my note. The NP was asked if Resident #1 had any injuries. The NP stated, I put generalized scratches to arms and legs . The NP stated, I saw him on the 8th (1/8/2021 after the first elopement). The NP was asked if Resident #1 was still having exit seeking behaviors. The NP stated, Yes, he would constantly ask, 'How do I get out?'. The NP stated that she was in the building the second time Resident #1 eloped. The NP was asked if she assessed Resident #1 when he came back in. The NP stated, Yes. The NP was asked if Resident #1 had any injuries. The NP stated, An abrasion to his right elbow and the old scabbing areas. During a telephone interview on 1/21/2021 at 5:04 PM, Licensed Practical Nurse (LPN) #1 confirmed she was working on 1/5/2021 when Resident #1 eloped. LPN #1 stated, One of the techs had seen him coming in to work, saw him walking down the highway, one of the other techs got in his car and went and got him (Resident #1) before I even knew he was gone. They brought him back, then we got to looking into how he got out .he had went in the room and had went to the window and pushed the screen out and had gotten out. LPN #1 was asked if she knew that CNA #4 had left the facility to go get Resident #1. LPN #1 stated, I knew someone had called it in and by the time it got to me on the floor he was coming back in .I was passing medications. It was right around 6ish (6:00 PM) .we were trying to get supper finished up and get everyone ready for bed. LPN #1 was asked when last she saw Resident #1. LPN #1 stated, 5:30 (PM) maybe, it wasn't that long. LPN #1 was asked if Resident #1 had a history of [REDACTED]. LPN #1 stated, Yes. LPN #1 was asked if she had received any in-services related to elopement or wandering. LPN #1 stated, I cannot remember. LPN #1 was asked if she had participated in any elopement drills. LPN #1 stated, No. LPN #1 was asked if Resident #1 had any injuries after the elopement on 1/5/2021. LPN #1 stated, Where he had fallen down, he was bloody everywhere. He had 2 spots on the end of each 3rd finger that I had to put a steri-strip (thin adhesive bandage to close the wound) on. They (staff) said he fell down into the ditch, it was just minor scrapes LPN #1 was asked if Resident #1 should have been monitored for injuries from the fall for 72 hours. LPN #1 stated, It should have been, but I don't know .they moved him to the lock down unit (Secure Unit). LPN #1 was asked if she gave report to the receiving nurse. LPN #1 stated No, I think (DON) did . During an interview on 1/22/2021 at 8:45 AM, LPN #2 was asked when Resident #1 was last seen before he eloped on 1/14/2021. LPN #2 stated, He was walking in the hall with the other residents. I went to the bathroom and I heard them yell (Resident #1) is outside. It was like a minute. During an interview on 1/25/21 at 5:13 PM, PT #1 was asked if Resident #1 was a part of her case load. PT #1 stated Yes. PT #1 was asked to describe Resident #1's gait. PT #1 stated, It depends on how fatigued he was, if he was fatigued, he would get the forward lean and not do as well with foot clearance . PT #1 was asked how much time had passed from the last time she saw Resident #1 in the hallway until she saw him outside on 1/14/2021. PT #1 stated, Not very long .5-10 minutes .he was quick. Review of the National Weather Service records, the recorded temperature on 1/5/2021 at 5:53 PM was 49 degrees Fahrenheit. Review of the National Weather Service records, the recorded temperature on 1/14/2021 at 10:53 AM was 53 degrees Fahrenheit. The surveyors verified the Removal Plan by: 1. On 1/22/2021, when the IJ was identified, the Corporate Regional Nurse Team and Medical Director were notified immediately and discussed the facility's failure to ensure the residents' environment remained as free of accident hazards as possible, the facility ensured each resident received adequate supervision, assessments for wandering, and monitoring to prevent elopement. The Corporate Nurse team also reviewed the facility elopement policy, supervision and monitoring. A root cause analysis was performed. It was determined the root cause of the deficient practice was related to lack of education, lack of administrative oversight, and failure to follow policy to complete an elopement risk assessment after the resident's first elopement. The surveyors interviewed the Corporate Nurse and Administrator. 2. On 1/5/2021, Resident #1 was immediately placed on the Secured Unit and orders were received, and he was assessed for appropriateness of placement on the Secured Unit. The surveyors reviewed the orders and assessment. 3. On 1/14/2021, Resident #1 eloped, was found and returned to the facility. It was determined that Resident #1 needed 1 on 1 observation. The Care Plan for Resident #1 was updated by the MDS Coordinator. Resident #1 remained on 1 on 1 observation until he was sent to a Geriatric Unit on 01/15/2021 where he remains. The surveyors reviewed Resident #1's Care Plan. 4. On 1/22/2021, all residents were assessed for elopement, wandering and fall risks by the MDS Coordinator, Director of Nursing, and the Unit Manager. Any concerns identified have been addressed and Care Plans have been updated. The surveyors reviewed the assessments, interviewed staff nurses on all shifts, Unit Managers, and the DON. 5. On 1/22/2021, all residents had been assessed and changes made on residents that had been determined to be at risk for falls and wandering/elopement by the staff nurses and verified by the DON/Unit Managers. The surveyors reviewed the assessments and interviewed staff nurses on all shifts and the DON. 6. On 1/22/2021, in-service training was implemented by the DON, Administrator, the Divisional Vice President (VP) of Operations, and designees in which they reeducated facility staff on keeping facility environment as free of accident hazards as possible, that each resident received adequate supervision and monitoring, residents were assessed to prevent elopement and falls. No staff member will be allowed to participate in resident care and or services until the staff member is trained. The type of training provided and topic were: New Elopement policy revised and implemented 1/22/2021 Elopement risks Supervision and monitoring Safe Environment Reporting Elopement Fall risks Elopement Drills The surveyors reviewed the revised policy, in-service trainings, and interviewed staff on all shifts. 7. On 1/22/2021, all resident Care Plans were reviewed with individualized person-centered interventions implemented to include supervision and monitoring for elopement risk and falls by the MDS Coordinator, Social Services, and the DON. The surveyors reviewed the Care Plans, and interviewed staff nurses on all shifts, Unit Managers, and the DON. 8. On 1/22/2021, all elopement binders had been assessed and changes made on residents that had been determined to be elopement risks. The surveyors reviewed the elopement binder. 9. On 1/22/2021, elopement drills began on alternating shifts and will continue weekly until compliance is determined by the Quality Assurance Performance Improvement (QAPI) committee and Regional Corporate Nurse Team. The surveyors reviewed the elopement drills, observed an elopement drill conducted on 1/25/2021, and interviewed staff on all shifts. 10. Beginning on 1/22/2021 daily rounding with direct observation will be conducted by the facility Administrator, DON and Unit Managers to monitor Care Plan updates, using the 24-hour report. The surveyors interviewed members of the Administration. 11. All windows have been secured. The Resident that eloped used a spoon to unscrew each screw of the window. All residents on the Secure Unit will now utilize disposable utensils. The windows will be checked daily by Maintenance and/or Housekeeping to determine the security of the windows 2 times daily for 1 week and then daily thereafter. The surveyors checked the windows and observed residents using plastic utensils. 12. All findings will a be reported to the special weekly QAPI meetings consisting of the QAPI Committee Team members, Administrator, DON, Assistant Director of Nursing, Medical Director, Business Office Manager, Dietary Manager, Maintenance Director, MDS Nurse, Director

Based on job description review, policy review, medical record review, facility incident report review, facility in service sign in sheets review, facility Performance Improvement Plan (PIP) review, and interview, the facility Administration failed to provide oversight and training of staff, ensure staff supervision, and ensure a safe environment for 1 of 3 sampled residents (Resident #1) reviewed for effective administration. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide adequate supervision related to the facilty's failure to maintain the well-being of a resident with known wandering and exit seeking behaviors when Resident #1 exited the building through a window without staff knowledge and was found 585 feet from the facility. Then, 9 days later, the same resident exited the building through a window and was located 209 feet from the facility. The Administrator, and the Director of Nursing (DON) were notified of the IJ on 1/22/2021 at 4:17 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689, F-835, and F-867. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted 1/22/2021 through 1/27/2021. The Immediate Jeopardy was effective from 1/5/2021 through 1/26/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 1/23/2021 at 6:30 PM, and was validated onsite by the surveyors on 1/24/2021-1/27/2021 through interviews, review of the Ad hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheet, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's Administrator job description, revised 1/2015, showed, .The primary purpose of your job description is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations .to assure that the highest degree of quality care can be provided to our residents at all times .Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board .Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program . Review of the facility's Director of Nursing Services job description, dated 2/2015, showed, .The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department .to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate and direct the nursing service department as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Develop nursing systems to implement, and maintain an ongoing Quality Assurance Process Improvement program for the nursing service department . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, stated, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering . Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS/GENERAL, showed, .All unusual occurrences or incidents will result in the Medical Director being notified .Accidents or incidents involving a resident shall be charted in the medical record .All details are to be recorded in the nurses' notes, including disposition and follow up care for a period of seventy-two (72) hours . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurses' Notes dated 12/24/2020, showed that Resident #1 was wandering aimlessly through hallways. Review of a Behavior Note dated 12/25/2020, showed that Resident #1 wandered around the facility for the majority of the shift and was trying to exit out of both doors of the unit. Review of a Nurses' Notes dated 12/25/2020, showed that Resident #1 had repeatedly tried to exit the facility by the fire exit and the COVID door entrance. Review of Nursing Notes and Elopement Incident Reports dated 1/5/2021 showed Resident #1 eloped from the facility through a window and was located in a deep rock lined ditch across a busy 2 lane state highway. The resident had multiple abrasions on his hands, thighs, knees, and scalp. There was no documentation that Resident #1 fell on this Elopement Incident Report. The facility was unable to provide any wandering, elopement, or fall risk assessments for Resident #1 after the incident on 1/5/2021. Review of a facility document titled, PIP (Performance Improvement Project): Resident Elopement, dated 1/6/2021, showed, .Social Services to complete elopement assessments on all residents in the facility. Risk assessments to be completed by nursing on all residents in the facility .Education to be completed with nursing concerning completing incident reports, documenting on the 24 hour report and notifying nursing management by 01/15/21 (2021) .Risk Team to discuss weekly and ensure that risk assessments and elopement assessments are completed on admission, with a change in status, and quarterly . Review of a facility document titled, In-Service Sign In Sheet, dated 1/6/2021, showed, .code silver wandering/elopement . There were 21 signatures of the 86 employees listed on the in-service. The facility was unable to provide documentation that all facility staff had received the in-service training on 1/6/2021. Review of the Nurses' Notes dated 1/6/2021-1/8/2021, showed no documentation of measurements of the injuries sustained in the elopement or any monitoring of the resident for additional injuries from the fall sustained on 1/5/2021, as indicated in the facility policy (that documentation is to be recorded in the Nurses' Notes including disposition and follow up care for a period of 72 hours). During an interview on 1/20/2021 at 2:42 PM, the Director of Nursing (DON) confirmed that skin assessments should include measurements of the areas documented on the assessment. The DON was asked if anyone had reported to her that Resident #1 was trying to open windows on the secured unit with a fork. The DON stated, No. The DON was asked if this should have been reported. The DON stated, I would think they would. During an interview on 1/20/2021 at 3:48 PM, the DON was asked why an incident report was not completed related to the fall on 1/5/2021. The DON stated, He didn't say he fell .we did an elopement (incident report). The DON was asked if a fall during an elopement should be documented in the elopement report. The DON stated, Yes . The DON confirmed a fall risk assessment was not completed on Resident #1 after the fall on 1/5/2021. During a telephone interview on 1/21/2021 at 5:04 PM, Licensed Practical Nurse (LPN) #1 was asked if Resident #1 had any injuries as a result of the elopement on 1/5/2021. LPN #1 stated, Where he had fallen down, he was bloody every where. He had 2 spots on the end of each 3rd finger that I had to put a steri-strip (thin adhesive bandage to close the wound) on. They (staff) said he fell down into the ditch, it was just minor scrapes . LPN #1 was asked if Resident #1 should have been monitored for injuries from the fall for 72 hours. LPN #1 stated, It should have been, but I don't know .they moved him to the lock down unit (Secure Unit). LPN #1 was asked if she gave report to the receiving nurse on the Secure Unit. LPN #1 stated No, I think (DON) did. Review of a Behavior Note dated 1/8/2021, showed that Resident #1 was trying to elope, trying to open the window with a fork, and all sharp objects were removed to ensure his safety. Review of a facility document titled In-Service Sign In Sheet dated 1/13/2021, showed, .Incident Reports Completed on Your Shift .Assess Residents .Statements .Intervention -Vitals .Call Physician/Family .Document In Nurses Note With Family (symbol for and) Physician Notification .Continue Documentation X (times) 3 Days All Shifts .Ensure Interventions Are Working . Six of 13 nurses had signed the in-service. The facility was unable to provide documentation that all nursing staff had received the in-service training on 1/13/2021. Only 6 of the 13 nurses had signed the in-service. Review of a Behavior Note dated 1/14/2021, showed that Resident #1 eloped at about 10:45 AM by crawling out of another resident's room window. Review of the facility's investigation showed an elopement incident report dated 1/14/2021. The facility was unable to provide wandering or elopement assessments for Resident #1 after the elopement on 1/14/2021. During interview on 1/19/2021 at 12:29 PM, the Director of Maintenance confirmed he was doing window checks twice a day on all windows. The Maintenance Director was asked why he was doing the window checks. The Maintenance Director stated, .close to the second incident that occurred (on 1/14/2021) I was down there (Secure Unit) .he (Resident #1) had a piece of plastic fork and trying to take a screw out (of the window). I told my assistant (Maintenance Assistant) we need to start checking these windows The Director of Maintenance was asked if he mentioned this to Resident #1's Nurse or anyone other than his assistant. The Director of Maintenance stated, Yes, the Director of Nursing and the nurse, the nurse actually saw him do it . During an interview on 1/19/2021 at 4:46 PM, Certified Nursing Assistant (CNA) #1 was asked about Resident #1's behaviors on 1/14/2021. CNA #1 stated .Before I found out about the incident, I caught him in another room trying to unscrew the window with a tool of some sort .Trying to find exits all day long, asking for a door to get out of this place. CNA #1 was asked if this was the same day Resident #1 eloped. CNA #1 stated, Yes .I let the nurse know. During an interview on 1/20/2021 at 4:38 PM, the Administrator was asked if anyone had notified her that Resident #1 was trying to get out windows on the secure unit. The Administrator stated, No. The Administrator was asked if staff should have notified her. The Administrator stated, Yes definitely. During an interview on 1/20/2021 at 4:55 PM, the Social Services Director was asked if she was aware of Resident #1's elopements. The Social Services Director stated Yes. The Social Services Director was asked if she completed elopement assessments on Resident #1 after the elopements. The Social Services Director stated, No. The Social Services Director was asked if she completed elopement assessments on any other residents as a result of the elopements. The Social Services Director stated, No. The Social Services Director was asked, if any elopement assessments were completed after the elopements, what would have prompted them to be done. The Social Services Director stated, They popped up on (Named electronic documentation system) that they (elopement assessments) were due. During an interview on 1/21/2021 at 2:14 PM, the DON confirmed the wandering and elopement assessment after Resident #1's elopement on 1/5/2021 and 1/14/2021 had not been done. The DON was asked if the risk assessments described in the PIP were completed on all residents. The DON stated, They are now. The DON was asked when they were completed. The DON stated Yesterday (1/20/2021). The DON was asked when they should have been completed. The DON stated, By the date it says on that paper (reviewed the copy of the PIP) .By the 15th. The DON was asked how many of the staff were in-serviced. The DON stated, As many as the signatures on the paper I gave you (referring to an in-service dated 1/13/2021). The DON was asked how many nurses should have been in-serviced. The DON stated, All of them. During an interview on 1/21/2021 at 5:27 PM, the Medical Director was asked if he knew Resident #1 had eloped on 1/5/2021 and again on 1/14/2021. The Medical Director stated, I think I knew about the one on the 5th. (1/5/2021) The Medical Director confirmed that he should have been notified of both elopements. During an interview conducted on 1/22/2021 at 10:00 AM, the Administrator and DON were asked whose responsibility it was to make sure the PIP was completed by 1/15/2021. The Administrator stated, It was mine. The Administrator and DON were asked when risk assessments were completed on residents. The DON stated, 1/20 (1/20/2021). The Administrator was asked if they should have been completed before 1/20/2021. The Administrator stated, Yes. The Administrator was asked if she came to the facility on [DATE] when Resident #1 eloped. The Administrator replied, .I did not .(DON) was here . The Administrator was asked if she had a meeting about the elopement. The Administrator stated she had a morning meeting about this elopement the next day. She was then asked if a plan had been developed. The Administrator stated, .We did wandering assessments . The Administrator was asked which residents had been assessed for wandering and she stated, .Everyone in the wandering book . The Administrator was asked if wandering assessments had been completed on other residents in the building. The Administrator stated, .I'll have to check with Social services . The Administrator and DON were asked how many nurses should have been educated on completing incident reports, documenting on the 24 hour report and notifying management by 1/15/2021. The DON stated, It should have been all. The Administrator and DON were asked how many nurses were in-serviced and on what date. The Administrator stated, For incident report 6 (nurses of the 13 nurses) on 1/13 (1/13/2021) . The Administrator and DON were asked if all nurses were in-serviced by 1/15/2021. The DON stated, No, because we have more nurses than that. During an interview on 1/22/2021 at 4:15 PM, the Administrator was asked if she was ultimately responsible for making sure a PIP gets implemented, staff are educated, assessments are performed, and residents are safe. The Administrator stated, Ultimately, yes. Refer to F-689 and F-867 The surveyor verified the Removal Plan by: 1. On 1/22/2021, when the deficient practice was identified, the facility Administrator notified the Corporate Regional Nurse Team and Medical Director immediately. The Divisional Vice President (VP) of Operations along with the Medical Director were informed along with the Corporate Regional Nurse Team and discussed the issues relative to the citation. They also reviewed the Elopement policy. It was determined during review, the root cause analysis the deficient practice was related to lack of education of staff including [MEDICATION NAME] and lack of oversight from administration. The surveyors interviewed the Administrator and Corporate Nurse. 2. On 1/22/2021, the Divisional VP of Operations educated the Administrator and the Director of Nursing regarding adequate supervision and system placement to monitor and ensure measures after an elopement are followed. The surveyors reviewed the education and interviewed the Administrator and DON. 3. On 1/22/2021-1/23/2021, a 100% audit of Care Plans was completed to ensure that all have been updated to reflect the supervision and monitoring of any elopement risk residents by MDS Coordinator, Social Service, and the Director of Nursing. The surveyors reviewed the audits and interviewed the MDS Coordinator, Social Services, and DON. 4. On 1/22/2021, the Administrator, DON/Designees began in-service training to all staff to prevent and recognize risk for elopement. The Divisional VP of Operations reeducated facility Administrator and Director of Nursing on individualized person-centered interventions, elopement risks, and safety. No staff member will be allowed to participate in resident care and or services until the staff member is trained. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 5. On 1/22/2021, all residents were assessed for elopement risks by the MDS Coordinator, Director of Nursing, and nursing staff. Any concerns have been addressed and Care Plans have been updated. The surveyors reviewed assessments and interviewed the MDS Coordinator, DON, and nursing staff. 6. On 01/22/2021, all residents have been assessed and changes made on residents that have been determined to be at risk for elopement by staff nurses and this was verified by the DON/Assistant Director of Nursing (ADON). The surveyors reviewed the assessments and interviewed the staff nurses and the DON. 7. On 01/22/2021, all elopement binders have been assessed and changes made on residents that have been determined to be elopement risks by staff nurses, MDS Coordinator, Unit Managers, and the DON. The surveyors reviewed the elopement binder and interviewed staff nurses, MDS Coordinator, Unit Managers, and the DON. 8. On 1/22/2021, monitoring of the 24-Hour report in daily clinical meeting began which includes, Administrator, DON, and Unit Managers, to see if any care plan changes are needed related to supervision and monitoring. The surveyors interviewed members of the clinical meeting team. 9. On 1/22/2021, elopement drills began on alternating shifts. These drills are to be conducted by facility Administrator, Director of Nursing or Unit Manager weekly until compliance is determined through QA committee and Regional Corporate Nurse Team. The surveyors reviewed the elopement drills, observed an elopement drill conducted on 1/25/2021, and interviewed staff on all shifts. 10. The Administrator will monitor on a weekly basis all audits for the next 4 weeks to ensure compliance; every 2 weeks for 4 weeks; and monthly thereafter in accordance with QAPI outcomes. All findings will also be reported to special weekly QAPI meetings consisting of the Quality Assurance (QA) Committee Team (Administrator, DON, Medical Director, Business Office Manager, Dietary Manager, Maintenance Director, MDS Coordinator, Director of Rehabilitation, Human Resources Director, Admissions Director, Marketing Director, Medical Records Staff, Environmental Services Director, Activities Director and Central Supply Staff) and Regional Clinical Team. Any findings may result in disciplinary action in accordance with facility policies and procedures. QAPI committee will resume on monthly basis once the committee deems compliance in a manner that is appropriate. During these QAPI meetings audits will be taken of all monitoring and education. The surveyors interviewed members of the QA team. 11. Evidence of Corporate oversight will be accomplished with review of audits and checklist of audits with the signatures of the Divisional VP of Operations or the Corporate Clinical Team on a weekly basis for the next 4 weeks to ensure compliance; every 2 weeks for 4 weeks; and monthly thereafter in accordance with QAPI outcomes. The surveyors interviewed members of Administration. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, facility in-service sign in sheet review, facility Performance Improvement Plan (PIP) review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to elopement, failed to develop and implement corrective actions and performance improvement activities for elopement to provide a safe environment for residents, and failed to ensure systems and processes were in place and consistently followed by staff and administration. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy when 1 of 3 sampled residents (Resident #1) at risk for elopement exited the facility by crawling through a window and was located approximately 585 feet from the facility. Then, 9 days later, the same resident exited the building again through a window on the Secure Unit hall and was found approximately 209 feet from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 1/22/2021 at 4:17 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689, F-835, and F-867. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted 1/22/2021 through 1/27/2021. The Immediate Jeopardy was effective from 1/5/2021 through 1/26/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 1/23/2021 at 6:30 PM, and was validated onsite by the surveyors 1/24/2020 through 1/27/2021 through interviews, review of the Ad hoc (as needed) QAPI meeting sign in sheets, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Plan, revised 4/2014, showed, .The objectives of the QAPI Plan are to: Provide a means to identify and resolve present and potential negative outcomes related to resident care and services .Provide structure and processes to correct identified quality and/or safety deficiencies .Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans . Review of the facility's policy titled, Quality Assurance and Performance Improvement Program revised 4/2014, showed, .Adverse events are tracked, monitored and investigated as they occur .Action plans are implemented to prevent recurrence of adverse events .Performance improvement projects (PIPs) are initiated when problems are identified .Planning, conducting and documenting PIPs . Review of the facility's Administrator job description, revised 1/2015, showed, .The primary purpose of your job description is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations .to assure that the highest degree of quality care can be provided to our residents at all times .Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board .Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program . Review of the facility's DON Services job description, dated 2/2015, showed, .The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department .to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate and direct the nursing service department as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Develop nursing systems to implement, and maintain an ongoing Quality Assurance Performance Improvement program for the nursing service department . Review of the medical record showed, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document titled, PIP: Resident Elopement, dated 1/6/2021, showed, .Social Services to complete elopement assessments on all residents in the facility. Risk assessments to be completed by nursing on all residents in the facility . Education to be completed with nursing concerning completing incident reports, documenting on the 24 hour report and notifying nursing management by 01/15/21 (2021) .Risk Team to discuss weekly and ensure that risk assessments and elopement assessments are completed on admission, with a change in status, and quarterly . Review of a Behavior Note dated 1/14/2021, showed, Resident (Resident #1) eloped at about 10:45 am (AM), resident broke out (exited through) another resident window, and crawled out the window. Resident kept asking staff to help him find his keys so he can get his car and go to (Named Store). Resident was redirected through out (throughout) the morning. The facility was unable to provide documentation that elopement and wandering assessments had been completed on all residents in the facility as outlined in the PIP dated 1/6/2021. Review of a facility document titled, In-Service Sign In Sheet, dated 1/6/2021, showed, .code silver wandering/elopement . There were 21 signatures listed on the in-service. Review of a piece of paper provided by the facility with handwritten numbers, showed the facility had 86 employees. 21 of the 86 employees had attended the in-service. Review of a facility document titled In-Service Sign In Sheet, dated 1/13/2021, showed, .Incident Reports Completed on Your Shift .Assess Residents .Statements .Intervention-Vitals .Call Physician/Family .Document In Nurses Note With Family (symbol for and) Physician Notification .Continue Documentation X (times) 3 Days All Shifts .Ensure Interventions Are Working . 6 of 13 nurses had signed the in-service document. Review of a piece of paper provided by the facility with handwritten numbers, showed 10 full time and 3 travel nurses were employed by the facility during the time the in-services should have been completed. The facility was unable to provide documentation that all nurses employed at the facility had been provided education as outlined in the PIP dated 1/6/2021. Review of a facility document titled, In-Service Sign In Sheet, dated 1/14/2021, showed, .code silver wandering/elopement . There were 21 signatures listed on the in-service sign in sheet. 21 of the 86 employees had attended the in-service. The facility was unable to provide documentation that all staff employed at the facility had been provided education for 1/14/2021. The facility was unable to provide documentation that a plan had been put in place to assess other residents for wandering/exit seeking behaviors and prevent elopements after Resident #1's second elopement on 1/14/2021. During an interview on 1/20/2021 at 4:38 PM, the Administrator stated, The reason we didn't change the PIP (after the second elopement) was because he (Resident #1) was put on 1 on 1 (one staff member with Resident #1 constantly until he was transferred) and transferred to the psychiatric unit. There was no way to know that he was going to do that and tear that window apart. During an interview on 1/20/2021 at 4:55 PM, the Social Services Director confirmed she had not completed the elopement assessments on Resident #1 after the elopements on 1/5/2021 and 1/14/2021. The Social Services Director was asked if she completed elopement assessments on any other residents because of the elopements. The Social Services Director stated, No. During an interview on 1/21/2021 at 2:14 PM, the DON was asked to review Resident #1's medical record and identify if the wandering or elopement assessments were completed after Resident #1's elopements on 1/5/2021 and 1/14/2021. The DON stated, No ma'am . The DON was asked if the risk assessments described in the PIP were completed on all residents. The DON stated, They are now. The DON was asked when they were completed. The DON stated Yesterday (1/20/2021). The DON was asked when they should have been completed. The DON stated, By the date it says on that paper (reviewed the copy of the PIP) .by the 15th. The DON was asked who was responsible for conducting the in-services for the nursing staff that were outlined in the PIP dated 1/6/2021. The DON stated, Me or the only other RN I have is my Risk Manager . The DON was asked how many of the staff received the in-service. The DON stated, As many as the signatures on that paper (referring to an in-service dated 1/13/2021). The DON was asked how many nurses should have received the in-service. The DON stated, All of them. During an interview on 1/22/2021 at 10:00 AM, the Administrator and DON were asked whose responsibility it was to make sure the PIP was done. The Administrator stated, It was mine. The Administrator and DON were asked when risk assessments were completed on residents. The DON stated, 1/20 (1/20/2021). The Administrator was asked if the assessments should have been completed before 1/20/2021. The Administrator stated, Yes. The Administrator and DON were asked how many nurses should have been educated. The DON stated, It should have been all. The Administrator and DON were asked if all nurses received the in-service by 1/15/2021. The DON stated, No, because we have more nurses than that. The Administrator was asked if she considered an elopement to be a change in status. The Administrator stated, Yes. The Administrator was asked if Resident #1 should have had an elopement risk or wandering assessment completed after the elopements. The Administrator stated, Yes, he did. The Administrator and DON were asked to review the record and if there was an elopement or wandering risk assessment completed on Resident #1 after 1/5/2021 or 1/14/2021. The Administrator and DON confirmed no elopement or wandering risk assessments were completed. The Administrator and DON were asked if the facility has a weekly risk team meeting. The DON stated, Yes. The Administrator and DON were asked who is on the risk team. The DON stated, Me, (Risk Manager), MDS (Minimum Data Coordinator), Social Services, Restorative, and Dietary. The Administrator and DON were asked if a Risk Team meeting was held after the PIP. The DON stated Yes, we had one last week. The DON was asked if they discussed Resident #1's elopement. The DON stated, Yes. The DON was asked if they checked to see if Resident #1's assessments had been completed. The DON stated, No, not necessarily on him in general but we discussed all residents. The DON confirmed the risk team meeting was held 1/12/2021, 6 days after the resident eloped. During an interview on 1/22/2021 at 3:38 PM, the MDS Coordinator was asked if she is active in the QAPI committee. The MDS Coordinator stated, I'm active in everything . The MDS Coordinator was asked if the facility had weekly Risk team meetings. The MDS Coordinator stated, We have weekly focus meetings .We go over weights, falls, quality measures . The MDS Coordinator was asked if a PIP was done after Resident #1's elopement on 1/5/2021. The MDS coordinator stated, I was told there was, but I did not have a part in that PIP. The MDS coordinator was asked if there was any PIP for QAPI after the elopement on 1/14/2021. The MDS coordinator stated, We were all together that day, we were trying to get him to a psych (psychiatric) facility. The MDS Coordinator was asked if the facility reviews any paperwork prior to the admission of a resident. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if the facility knew Resident #1 was at risk for wandering when he was admitted . The MDS Coordinator stated, Yes. During an interview on 1/22/2021 at 4:15 PM, the Administrator was asked if she is ultimately responsible for making sure a PIP gets implemented, staff is educated, assessments are performed, and residents are safe. The Administrator stated, Ultimately, yes. Refer to F-689 and F-835 The surveyor verified the Removal Plan by: 1. On 1/22/2021, when the IJ was identified, Divisional Vice President (VP) of Operations, Corporate Regional Nurse Team and the Medical Director were notified immediately and discussed the facility's failure to complete elopement risk and wandering assessments, educate staff and follow their plan outlined in a PIP. The Medical Director, Divisional VP of Operations and the Regional Nurse Team performed a root cause analysis and determined that the deficient practice was related to lack of education and administrative oversight. The surveyors interviewed the Administrator and Corporate Nurse. 2. On 1/22/2021, the Divisional VP of Operations in-serviced the Administrator and DON and Assistant Director of Nursing (ADON) regarding the need for a system to monitor departmental performance data, communication, monitor resident safety and resident supervision, to ensure staff consistently identifies, investigates and attempts to determine the underlying cause of elopement. The surveyors reviewed the education and interviewed the Administrator and DON. 3. On 1/5/2021, Resident #1 was immediately placed on the Secure Unit, orders were received, he was assessed for appropriateness of the Secure Unit and then placed on the Secure Unit. The surveyors reviewed the orders and assessments. 4. On 1/14/2021, Resident #1 was located and returned to the facility and it was determined the resident needed 1 on 1 observation on that day. The Care Plan for the resident was updated by MDS. The resident remained 1 on 1 observation until he was sent to the Psychiatric hospital on [DATE], where he remains. The surveyors reviewed the Care Plan and 1 on 1 documentation. 5. On 1/22/2021, all residents were assessed for elopement, wandering and fall risks by the MDS Coordinator, DON, and Unit Managers. Any concerns have been addressed and Care Plans have been updated. The surveyors reviewed the assessments, the Care Plans, and interviewed the MDS Coordinator, DON, and the Unit Manager. 6. On 1/22/2021, all residents have been assessed and changes made on residents that have been determined to be at risk for falls and wandering/elopement by staff nurses, and Unit Managers. This was verified by the DON/ADON. The surveyors reviewed the assessments, interviewed staff nurses, and the DON. 7. On 1/22/2021, all elopement binders have been assessed and changes made on residents that have been determined to be elopement risks by staff nurses and this was verified by the DON/ADON. The surveyors reviewed the elopement binder, interviewed staff on all shifts, and the DON. 8. On 1/22/2021, the DON, Administrator, and the Divisional VP of Operations began in-service training. Facility staff were reeducated on keeping the facility environment as free of accident hazards as possible and that each resident received adequate supervision and monitoring to prevent elopement and falls. No staff member will be allowed to participate in resident care and or services until the staff member is trained. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 9. On 1/22/2021-1/23/2021, resident Care Plans were reviewed and updated with individualized person-centered interventions to include supervision and monitoring for elopement risk and falls by the MDS Coordinator and Social Services. The surveyors reviewed the Care Plans and interviewed the MDS Coordinator and Social Services. 10. On 1/22/2021, elopement drills began on alternating shifts and will continue weekly until compliance is determined through QA committee and Regional Corporate Nurse Team. The surveyors reviewed the elopement drills, observed an elopement drill conducted on 1/25/2021, and interviewed staff on all shifts. 10. Beginning on 1/22/2021, daily rounding by direct observation will be done by the facility Administrator, DON, and Unit Manager to monitor Care Plan updates using the 24-hour report. The surveyors reviewed the rounding audits and interviewed the Administrator and DON. 11. All findings will be reported to special weekly QAPI meetings consisting of the QAPI Committee Team consisting of the Administrator, DON, ADON, Medical Director, Business Office Manager, Dietary Manager, Maintenance Director, MDS Nurse, Director of Rehabilitation, Human Resources Director, Admissions Director, Marketing Director, Medical Records Staff, Environmental Services Director, Activities Director, and Central Supply. Weekly QAPI meetings will be zoomed (video meetings) and attended by the Corporate Nurse Team Designee and will be conducted weekly for 4 weeks then resumed on a monthly basis. The surveyors reviewed the QAPI sign in sheets and interviewed members of the QAPI team. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility documentation review, observation, and interview, the facility failed to ensure appropriate temperatures were maintained on 1 of 4 resident halls (Secure Unit) reviewed for comfortable environment. The facility's failure had the potential to affect the 12 residents residing in the Secure Unit of the 67 residents residing in the facility. The findings include: Review of the facility's policy titled, Quality of Life-Homelike Environment, revised 5/2017, showed, .Residents are provided with a safe, clean, comfortable and homelike environment .Comfortable and safe temperatures (71 (degrees) F (Fahrenheit) - 81 (degrees) F) . Review of the 24 Hour Report showed, .1/5/2021 .(Resident #30) says she is freezing in her room .1/7/21(2021) .All rooms are freezing. Residents do not want to sleep in cold rooms .01/10/2021 .No blankets available .undated .(Resident #31) offer to bring her to the dining room she refused .stated it was too cold. Patient room is very cold .(Resident #32) .refuses to stay in bed .states his room is too cold .01/22/2021 .Pt's (patients) c/o (complained of) being cold all night . During an interview on 1/20/2021 at 9:45 AM, the Director of Maintenance was asked if he had received any complaints from the residents or staff that the Secure Unit hall was cold. The Director of Maintenance stated, Yes .about 2 weeks ago .both units (Heating, Ventilation, and Air Conditioning (HVAC) units) was working about 70 percent and he (HVAC technician) replaced to a brand new unit .all he (HVAC technician) could get was one unit (had replaced 1 of 2 heating units for that hall) .I got a call and said it (Secure Unit hall) was cold .at 2 (2:00 AM) that night (unknown date) .the second unit wasn't even working .all the West Wing (Secure Unit hall) doesn't have (individual) units in their room .that (the 1 heating unit) should be efficient . Observation in the resident's room on 1/23/2021 at 8:40 AM, showed Resident #5 was lying in bed covered with a thin sheet and Resident #5 stated, .I'm freezing . There was a blanket lying on the overbed table. During an interview on 1/23/2021 at 8:43 AM, Certified Nursing Assistant (CNA) #5 was notified Resident #5 was cold and asked if the facility had any blankets. CNA #5 stated, Yes .It's usually not this cold . CNA #5 did not offer Resident #5 a blanket. Observation and interview in the Secure Unit on 1/23/2021 at 8:45 AM with the Director of Nursing (DON), showed the thermostat temperature to be 63 degrees F. DON confirmed the temperature was 63 degrees F on the thermostat. The DON was asked how the facility planned to keep the residents warm. The DON stated, Talked to Regional .they said to open the doors (doors leading to the facility from Secure Unit) . Observation in the resident's room on 1/23/2021 at 9:00 AM, showed Resident #33 seated on the side of the bed, eating breakfast and she stated, .it's cold in this place .I need some hot coffee .let's get warm .I'm cold . During an interview on 1/23/2021 at 9:15 AM, the Director of Maintenance stated, I got a call about 6:30 AM (on 1/23/2021), was cold back there .didn't know what to do . The Director of Maintenance confirmed both units were not working on 1/23/2021. During a telephone interview on 1/23/2021 at 4:35 PM, Licensed Practical Nurse (LPN) #3 was asked what time on Friday, 1/22/2021, were the staff aware the Secure Unit was cold. LPN #3 stated, That's every night .it's in the 24 hour report .it's in there every time I work . LPN #3 was asked what administration told them to do for the residents when it was cold on the Secure Unit. LPN #3 stated, .to get blankets and put on them .you don't notice it till (until) 2 (2:00 AM) or 3 (3:00 AM) in the morning .some residents sleep in the dining room because they are cold . LPN #3 was asked if she had reported the cold temperatures last night. LPN #3 stated, .I didn't say anything today because I've complained since I've been there .they say the hall is always this cold .we put extra blankets .some residents won't get out of the bed because they say it's cold . During an interview on 1/25/2021 at 7:37 AM, the Business Office Manager was asked if the Director of Maintenance was called when the Secure Unit hall was cold. The Business Office Manager stated, .yes .I got here 5:30 (5:30 AM on 1/23/2021) .would have to be around 6 (6:00 AM on 1/23/2021) .to let him know .temperature was set on 74 (degrees F) and was reading 65 (degrees F) .it was cold . During an interview on 1/25/2021 at 4:50 PM, the Director of Maintenance was asked what the temperature should be in the facility. The Director of Maintenance stated, .71-79 (degrees F). The Director of Maintenance was asked if the temperature should be 63 degrees F. The Director of Maintenance stated, No . The Director of Maintenance was asked if he had received any complaints related to the Secure Unit being too cold. The Director of Maintenance stated, .I'm thinking I got a call on 1/6 (1/6/2021) about the back room being chilly .couple more complaints .that's why I put the unit in the dining room .but it (the Secure Unit) needed the other unit .I think it was hard on it (the single unit) to function by itself . During an interview on 1/26/2021 at 11:00 AM, The Director of Maintenance was asked if 63 degree F temperature was a safe and appropriate environment for residents. The Maintenance Director stated, .I don't think so .I'm just going to be honest .I'm still learning . During an interview on 1/26/2021 at 11:10 AM, the Vice President of Operations was asked if a temperature of 63 degrees F was a safe and appropriate environment for residents. The Vice President of Operations stated, .I know what the regs (regulations) are .71-81 (degrees F) . The Vice President of Operations was asked what the temperature on the Secure Unit was at the time (1/23/2021 at 8:50 AM) when she checked the thermostat. The Vice President of Operations stated, 63 (degrees F) . During an interview on 1/27/2021 at 11:01 AM, the DON was asked if a temperature of 63 degrees F was a safe and appropriate environment for residents. The DON stated, No.

Based on observation and interview, the facility failed to prevent the spread of infection when 2 of 12 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to keep ice and drinks covered during dining. The findings include: Observation during dining on 12/16/19 at 12:00 PM, in the 400 hallway, showed a cart with beverages and ice in the hallway. CNA #1 removed the lid from a pitcher of ice, picked up a glass with her bare hand and scooped ice from the pitcher with the glass. CNA #1 then poured the ice into another glass, and placed the glass used as a scoop for the ice into the pitcher of ice. The drink cart with the exposed ice was wheeled down the 400 hallway past the nurses station to the next area of resident rooms. CNA #1 returned to the drink cart, removed the glass that was in the ice, scooped up ice with the glass, poured the ice into another glass and placed the glass used as a scoop back into the ice pitcher. CNA #1 then poured a beverage over the ice she had prepared and carried it uncovered down the hallway to the activities room and served it to a resident. CNA #2 poured ice from the uncovered ice pitcher into two glasses, returned the pitcher to the drink cart, leaving the ice uncovered. CNA #2 filled the glasses with tea and juice and served the glasses to a resident in room [ROOM NUMBER]. CNA #2 then poured ice from the uncovered ice pitcher into a glass, filled it with tea, and served the glass of tea to a resident in room [ROOM NUMBER]. During an interview conducted on 12/17/19 at 5:05 PM, the Director of Nursing (DON) confirmed that beverages and ice should be covered when transported in the hallway and when not in use. The DON was asked if a glass or scoop should be stored in the ice container. The DON stated, No, the proper procedure is to pour the ice from the pitcher into the glass. The DON was asked if the ice should have been used after the glass was placed on top of the ice in the ice pitcher. The DON stated, No, they should have obtained fresh ice .

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 5 nurses (Licensed Practical Nurse (LPN) #1, #2, and #3) failed to perform hand hygiene during medication administration to 3 of 5 residents (Resident #5, #29, and #266) observed during medication administration. The findings include: 1. Review of the undated facility policy titled, Handwashing/Hand Hygiene showed that hand hygiene should be performed before and after direct contact with residents, before preparing and handling medications, after contact with objects in the immediate vicinity of the resident, and after removing gloves. 2. Observation of medication administration in Resident #29's room on 12/17/19 at 10:15 AM, showed LPN #1 donned clean gloves to check the Percutaneous Endoscopic Gastrostomy (PEG) tube placement (use of a stethoscope to check for residual stomach contents). LPN #1 removed her gloves, touched the resident's left side rail, turned the water on, touched the sink, moved the resident's sheet, touched the resident's gown, donned clean gloves, and administered medication. LPN #1 failed to perform hand hygiene after the removal of gloves and before donning clean gloves. 3. Observation of medication administration in Resident #266's room on 12/18/19 at 9:05 AM, showed LPN #2 donned clean gloves, administered the [MEDICATION NAME] inhaler 18 micrograms (mcg), removed her gloves, rinsed the inhaler, turned off the water, touched the sink, touched the bedside table, donned clean gloves, removed the [MEDICATION NAME] handihaler capsule 18 mcg medication tab from the package, placed it in the inhaler chamber and administered the medication without performing hand hygiene before donning clean gloves and administering the [MEDICATION NAME] inhaler. 4. Observation of medication administration in Resident #5's room on East Short Hall on 12/18/19 at 10:20 AM, showed LPN #3 failed to perform hand hygiene prior to preparing and administering medications. 5. During an interview conducted on 12/18/19 at 2:04 PM, the Director of Nursing (DON) was asked if hand hygiene should be performed before and after donning gloves and prior to medication administration. The DON stated, Yes.

Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for 1 of 6 sampled residents (Resident #41) reviewed for oxygen therapy. The findings include: Review of the medical record showed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 10/31/19 showed .O2 (oxygen) 2l/min (liters per minute) PNC (per nasal cannula) for SOB (shortness of breath) or decrease O2 sat (saturation) . Observation in Resident #41's room on 12/16/19 at 3:27 PM and 12/17/19 at 7:42 AM, showed Resident #41 in bed with oxygen at 3l/min per nasal cannula. Observation in Resident #41's room on 12/17/19 at 2:56 PM, showed Resident #41 in bed with oxygen at 3 1/2 l/min per nasal cannula. During an interview conducted on 12/17/19 at 3:08 PM, the Director of Nursing (DON) was asked if Resident #41's oxygen was administered as ordered. The DON stated, No, ma'am, I will fix it.

Based on medical record review, and interview, the facility failed to ensure residents were accurately assessed for anticoagulant therapy and falls for 2 of 23 residents (Resident #25 and 56) reviewed. The findings include: 1. Review of the medical record, showed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] was coded to reflect anticoagulant use on 7 of 7 days. Review of the (MONTH) 2019 Medication Administration Record, [REDACTED]. During an interview conducted on 12/18/19 at 3:39 PM, the MDS Coordinator confirmed the 10/25/19 MDS was coded inaccurately. 2. Review of the medical record, showed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change assessment dated [DATE], showed Resident #56 had no falls. Review of an Incident/Accident Investigation Report dated 11/20/19, showed Resident #56 had a fall on 11/20/19 at 1:54 AM, resulting in a skin tear to the bridge of her nose and an abrasion to her right and left knee and an abrasion to her right elbow. Review of an Incident /Accident Investigation Report dated 11/21/19 showed Resident #56 had a fall on 11/21/19 at 10:04 AM, resulting in a hematoma (raised area) to her forehead. During an interview conducted on 12/18/19 at 3:45 PM, the MDS Coordinator confirmed that the significant change assessment dated [DATE] should have reflected the falls that Resident #56 sustained on 11/20/19 and 11/21/19.

Intakes: TN 822 Based on medical record review and interview, it was determined the facility failed to provide weekly skin assessments as care planned to prevent and identify skin breakdown for 1 of 4 (Resident #3) sampled residents for pressure ulcers, which resulted in actual harm when Resident #3 was admitted to the hospital with [REDACTED]. The findings included: Medical record review for Resident #3 revealed an admitted d of 5/1/13 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan, documented a problem of "Potential for skin breakdown d/t (due to) decreased mobility; frequently incontinent of B&B (bowel and bladder)..." and Approaches for this problem, "Weekly skin assessment..." Review of the latest weekly nursing summary dated 5/25/13, included a skin assessment and documented the only area of concern was left "2nd toe thick". The most recent wound assessment report prior to the weekly nursing summary of 5/25/13 was dated 5/15/13 and documented a pressure ulcer to the left ear. Review of Resident #3's daily skilled nurses notes for 5/1/13 through 5/29/13 revealed a checklist on the front of each daily note which documented a checkmark for "Skin Color Normal". There was no checkmark for "Decubitus Wound" or for "Pressure Ulcer Management" on these daily notes. Nurse's notes for Resident #3 dated 5/29/13 documented, 1:00 PM, "Pt (patient) noted to have (decreased) appetite. Pocketing food and liquids. M.D. (Medical Doctor) notified @ (at) this time..." 6:45 PM, "Pt family requesting that pt be sent to ER (emergency room ) for eval (evaluation). States he's not his usual self. Order received to send to ER for eval. On call nurse notified. EMS (emergency management service) notified and here @ this time to transport to ER. Family @ side... VS (vital signs): BP (blood pressure): 120/78 P (pulse) 58 R (respiration) 16 T (temperature) 97.9." Review of Resident #3's hospital records documented the resident arrived to the hospital on [DATE] at 6:12 PM. Presenting complaint was documented as, "...EMS states: pt sent from (named this facility). Mobile X-ray showed pneumonia per EMS report. Pt has not been eating x (times) 2 days. To have consult tomorrow for feeding tube. Family concerned that he is not acting normally. Unable to obtain an initial BP either by manual or auto cuff. Temp 87.8..." Triage assessment completed at 8:01 PM documented, "...Rash with fungal appearance on perineal area. Stage 2 decubitus on both buttocks..." The physician's "History and Physical" dictated 5/30/13 documented, "...The patient has multiple pressure ulcers. He has a stage 2 pressure ulcer on the right upper buttock. He has stage 3 ulcer on the left buttock... He has also a few more ulcers on both feet..." During a telephone interview on 9/26/13 at 9:00 AM, the Director of Nursing stated she was not aware Resident #3 was assessed to have pressure ulcers at the hospital. During a telephone interview on 9/26/13 at 1:30 PM, the Administrator verified there were no other skin assessments documented after 5/25/13. The facility failed to complete weekly assessments as care planned. The failure to identify stage 2 pressures resulted in actual harm to Resident #3.

Based on medical record review and interview, it was determined the facility failed to provide weekly skin assessments as care planned to prevent and identify skin breakdown for 1 of 4 (Resident #3) sampled residents for pressure ulcers, which resulted in actual harm when Resident #3 was admitted to the hospital with [REDACTED]. The findings included: Medical record review for Resident #3 revealed an admitted d of 5/1/13 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan, documented Problem, "Potential for skin breakdown d/t (due to) decreased mobility; frequently incontinent of B&B (bowel and bladder)..." and Approaches for this problem, "Weekly skin assessment..." Review of the latest weekly nursing summary dated 5/25/13, included a skin assessment and documented the only area of concern was left "2nd toe thick". The most recent wound assessment report prior to the weekly nursing summary of 5/25/13 was dated 5/15/13 and documented a pressure ulcer to the left ear. Review of Resident #3's daily skilled nurses notes for 5/1/13 through 5/29/13 revealed a checklist on the front of each daily note which documented a checkmark for "Skin Color Normal". There was no checkmark for "Decubitus Wound" or for "Pressure Ulcer Management" on these daily notes. Nurse's notes for Resident #3 dated 5/29/13 documented, 1:00 PM, "Pt (patient) noted to have (decreased) appetite. Pocketing food and liquids. M.D. (Medical Doctor) notified @ (at) this time..." 6:45 PM, "Pt family requesting that pt be sent to ER (emergency room ) for eval (evaluation). States he's not his usual self. Order received to send to ER for eval. On call nurse notified. EMS (emergency management service) notified and here @ this time to transport to ER. Family @ side... VS (vital signs): BP (blood pressure): 120/78 P (pulse) 58 R (respiration) 16 T (temperature) 97.9." Review of Resident #3's hospital records documented the resident arrived to the hospital on [DATE] at 6:12 PM. Presenting complaint was documented as, "...EMS states: pt sent from (named this facility). Mobile X-ray showed pneumonia per EMS report. Pt has not been eating x (times) 2 days. To have consult tomorrow for feeding tube. Family concerned that he is not acting normally. Unable to obtain an initial BP either by manual or auto cuff. Temp 87.8..." Triage assessment completed at 8:01 PM documented, "...Rash with fungal appearance on perineal area. Stage 2 decubitus on both buttocks..." The physician's "History and Physical" dictated 5/30/13 documented, "...The patient has multiple pressure ulcers. He has a stage 2 pressure ulcer on the right upper buttock. He has stage 3 ulcer on the left buttock... He has also a few more ulcers on both feet..." During a telephone interview on 9/26/13 at 9:00 AM, the Director of Nursing stated she was not aware Resident #3 was assessed to have pressure ulcers at the hospital. During a telephone interview on 9/26/13 at 1:30 PM, the Administrator verified there were no other skin assessments documented after 5/25/13. The facility failed to complete weekly assessments as care planned. The failure to identify stage 2 pressures resulted in actual harm to Resident #3.