Every finding on record at Courtyard Health and Rehabilitation

Based on observation, record review, facility policy review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (5) of seven (7) sampled residents, Resident #1, Resident #2, Resident #3, Resident #4 and Resident #6. Findings included:Record review of the facility policy titled, Safe and Homelike Environment with Revision Date 10/14/25, revealed the policy stated, In accordance with resident's rights, te facility will provide a safe, clean, comfortable and homelike environment.This includes ensuring that the resident can receive care and services safely and that the physical layout.does not pose a safety risk.Sanitary includes.preventing the spread of disease-causing organisms.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.On 6/17/26 at 1:38 PM, during a telephone interview the Resident Representative (RR) for Resident #1 reported that she complained that the facility did not provide a clean, sanitary environment and confirmed observations of houseflies, maggots (larva of houseflies) and gnats in the resident's room.On 6/17/26 at 3:40 PM and again at 5:00 PM, observations revealed a housefly in the lobby flying around Resident #2 repeatedly landing on his hands, arms and face. Resident #2 had a primary diagnosis of cerebral palsy and was not able to speak or move his hands/arms in a meaningful way or swat the housefly away.On 6/17/26 at 3:50 PM, observation and interview with Resident #1 revealed there was a housefly in the resident's room which distracted her during interview and she swatted at it repeatedly. The State Agency (SA) was able to speak limited conversational Spanish, coupled with the use of cellular telephone for translation, was able to have a conversation with Resident #1, who was neat, clean, and free from malodorous smells. Her demeanor was pleasant, calm and welcoming. She was able to understand and answer simple questions in Spanish.On 6/17/26 at 4:00 PM, observation and interview with Resident #4 in the hallway (100 Hall) and lobby revealed a housefly that repeatedly landed on her hands, arms and purse as she attempted to retrieve an item from her purse. Resident #4 swatted at the fly and confirmed that the fly was irritating her.On 6/17/26 at 4:10 PM, observation and interview with Resident #3 in the hallway (300 Hall) and lobby revealed a housefly flying around her and landing on her arms and hands with the resident swatting the fly and attempting to shoo the fly away. Resident #3 reported, The flies and the gnats are bad and confirmed that the pests annoyed and irritated her.On 6/18/26 at 1:20 PM, during observation and interview with the RR for Resident #2 in the resident's room revealed the RR reported repeated observation of pests, specifically houseflies, gnats and spiders, in the resident's room. Observation revealed a dead spider in a cobweb in the bottom right corner of the resident's room (corner under the window on the right of the window when viewed from the doorway into the room).On 6/18/26 at 1:35 PM, during interview with the Housekeeping Accounts Manager confirmed the dead insect observed in the room of Resident #2 looked like a spider. On 6/18/26 at 2:22 PM, observation and interview with Resident #6 revealed a housefly in the resident's room and the resident stated that he had not been impressed by the housecleaning or cleanliness of his room and that the houseflies bothered him. The SA observed a strong urine smell in the hallway (100 Hall) outside the resident's room which was very strong in his room. Resident #6 stated that he thought he had acclimated to the odor but said that he was able to see the urine on the floor coming out from under his bed and running along the wall under the window approximately four (4) feet to the corner.On 6/18/26 at 4:10 PM, during interview the Director of Nurses (DON) confirmed that contracted pest control service would visit and provide treatment if notified of pests in the building.On 6/18/26 at 4:40 PM, an interview with the Administrator confirmed that the contracted pest control service would visit and provide treatment if notified of pests in the building.On 6/18/26 at 5:00 PM, during an interview with the Infection Preventionist (IP) she confirmed that she had observed houseflies in residents' rooms and in common areas. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 6/11/25 and the resident had diagnoses of senile degeneration of brain, dementia, Alzheimer's Disease, anxiety, restlessness and agitation.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 3/20/26 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score as 0 which indicated severe cognitive impairment.Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 5/31/18 and the resident had diagnoses of cerebral palsy, anxiety and adult failure to thrive.Record review of the Quarterly MDS with an ARD of 5/13/26 for Resident #2 revealed the facility assessed the resident unable to participate in interview and documented memory problems and severe impairment of cognitive skills for daily decision making.Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 12/09/16 and the resident had diagnoses of osteoarthritis, diabetes and anemia.Record review of the Annual MDS with an ARD of 3/29/26 for Resident #3 revealed the facility assessed the resident's BIMS score as (15) which indicated resident #3 was cognitively intact.Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 2/27/15 and the resident had diagnoses of hemiplegia and hemiparesis following cerebrovascular disease and Parkinson's Disease.Record review of the Annual MDS with an ARD of 5/20/26 for Resident #4 revealed she had a no BIMS score and documented no memory problem and no impairment of cognitive skills for daily decision making.Record review of the admission Record for Resident #6 revealed the facility admitted hm on 3/06/26 and he had diagnoses of heart failure, sepsis (unspecified organism acute infection present on admission), retention of urine, stage 3 chronic kidney disease, and stage 3 pressure ulcer of right button (present on admission).Record review of the Significant Change MDS for Resident #6 with an ARD of 5/21/26 revealed a BIMS score of 13, which indicated the resident was cognitively intact.

Based on observations, record review, facility policy review and interviews the facility failed to ensure that staff followed standard and transmission-based precautions to prevent spread of infections, when an Registered Nurse (RN) did not follow Enhanced Barrier Precautions (EBP) during direct care/replacement of the resident's leaking catheter drainage and collection component for one (1) of two (2) sampled residents with indwelling catheters. Resident #6. Findings Included:Record review of the facility policy titled, Standard Precautions Infection Control with Revision Date 11/14/25 revealed the policy stated, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes.selection and use of PPE e.g., gloves, gowns.environmental cleaning and disinfection.Resident-Care Equipment and Instruments/Devices: a. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments/devices that may be contaminated with blood or body fluids. Personnel are trained in the use of these procedures. b. Wear PPE (e.g., gloves, gowns, etc.) when handling resident-care equipment and instruments/ devices that are visibly soiled or may have been in contact with blood or body fluids.Gown During procedures and resident-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated.On 6/18/26 at 2:22 PM, observation and interview with Resident #6 revealed a strong urine smell in the hallway (100 Hall) outside the resident's room which was very strong in his room. There was a posted notice (with pictures as well as printed instructions) that gowns and gloves were required for contact procedures on the door of the room of Resident #6 for EBP. Resident #6 stated that he thought he had acclimated to the odor but said that he was able to see the partially dried urine on the floor coming out from under his bed. Observation revealed the resident had catheter tubing extending from under his bed covers onto the floor and up to a urine collection bag with three (3) inches of the catheter tubing laying on the floor next to the resident's bed in urine that covered an area of four (4) feet by three (3) inches under the resident's bariatric bed and continued to cover an additional area four (4) feet long by one (1) foot wide along the wall under the window to the wall/corner on the right side of the window as viewed from the doorway into the room.On 6/18/26 at 3:30 PM, observation revealed the facility Infection Preventionist (IP)/RN #1 confirmed that there was urine on the floor of Resident #6's room and that his catheter bag was leaking. RN #1 changed the tubing and urine collection bag for Resident #6 without donning a disposable gown, which was required according to EBP. The resident's catheter was not changed.On 6/18/26 at 4:10 PM, during an interview the Director of Nursing (DON) confirmed that no catheter tubing should be on the floor for infection prevention, and she expected nursing staff to wear appropriate personal protective equipment (PPE) for the direct care of residents on EBP.On 6/18/26 at 4:30 PM, during an interview the Administrator revealed he expected nursing staff to wear appropriate PPE for the direct care of residents on EBP and follow current infection prevention standards of practice.On 6/18/26 at 5:00 PM, in an interview the IP confirmed that Resident #6, along with all residents with urinary catheters, was on EBP and that RN #1 had failed to wear a disposable gown for direct care while changing the catheter tubing and urine collection container for Resident #6 at 3:30 PM on 6/18/26. Record review of the admission Record for Resident #6 revealed the facility admitted him on 3/06/26 and he had diagnoses of heart failure, sepsis (unspecified organism acute infection present on admission), retention of urine, stage 3 chronic kidney disease, and stage 3 pressure ulcer of right button (present on admission).Record review of the Significant Change Minimum Data Set (MDS) for Resident #6 with Assessment Reference Date (ARD) 5/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The facility assessed the resident was dependent for all activities of daily living and had active diagnoses of neurogenic bladder and urinary tract infection (UTI) and had an indwelling catheter.

Based on observation, record review, facility policy review, and interview, the facility failed to ensure that a Spanish-speaking resident had access to language assistance services to prevent cultural and language barriers to care and quality of life for one (1) of (1) Spanish-speaking resident reviewed for communication needs. Resident #1. Findings included:Record review of the facility policy titled, Non-Discrimination-Language Assistance Services with Revision Date 10/14/25 revealed, It is the policy of this facility to take reasonable steps to ensure that individuals with Limited English Proficiency (LEP) are not discriminated against and have access to language assistance services and meaningful communication involving their medical conditions, treatment, and other vital documents.Language assistance will be provided in-person or remotely by a qualified interpreter and/or the use of qualified bilingual or multilingual staff.The facility must not.Rely on staff other than qualified interpreters, qualified translators, or qualified bilingual/multilingual staff to communicate with individuals with LEP If the facility provides a qualified interpreter for an individual with LEP through video remote interpreting services, the facility must ensure the modality allows for meaningful access and must provide.Adequate training to users of the technology and other involved persons so that they may quickly and efficiently set up and operate the video remote interpreting services .On 6/17/26 at 12:10 PM, during an interview the Director of Nurses (DON) revealed the facility had a tablet that was portable and video remote interpreting services to facilitate communication with Resident #1, who had been assessed upon admission and since as Spanish speaking. She confirmed that there was not a communication board for use in communication with Resident #1. On 6/17/26 at 12:15 PM, during an interview the Administrator reported that the facility had one non-English speaking resident, Resident #1, and that the facility had obtained a portable tablet and video remote interpreting services to facilitate communication with Resident #1.On 6/17/26 at 1:15 PM, during an interview CNA #1 revealed she did not utilize the facility tablet with translator services provided by the facility and had not received training regarding its use for communication with Resident #1.On 6/17/26 at 1:18 PM, interview with CNA #2 revealed she reported that she used pointing with her finger and hand gestures to communicate with Resident #1 and did not utilize the facility tablet with translator services provided by the facility and had not been provided training regarding its use for communication with Resident #1.On 6/17/26 at 1:21 PM, during an interview, CNA #3 said she pointed (with her finger) to communicate with Resident #1. She reported she did not utilize the facility tablet with translator services provided by the facility and had not received training regarding its use for communication with Resident #1. She stated she wasn't sure but that being able to communicate with Resident #1 in Spanish could positively impact resident care and redirection of the resident as needed. On 6/17/26 at 1:38 PM during telephone interview the Resident Representative (RR) for Resident #1 voiced concern that the resident was portrayed as noncompliant and combative because the facility staff did not use any translator or communication aides to communicate with Resident #1, who spoke Spanish and little to no English. The RR said that they would not call her to translate or try to communicate with the Resident, especially during incidents to try to deescalate episodes of resistance to care or combativeness.On 6/17/26 at 2:28 PM, interview and observation with the Social Services Director (SSD) revealed the facility had procured a tablet and subscribed to a language translation service to provide a method of communication between Resident #1 and health care staff. The tablet was secured on a rolling stand for mobility, and the SSD confirmed it was kept in her office. She confirmed that she locked her office when she left the facility Monday through Friday afternoons and that it was available to nursing staff as needed. She said that she was not aware of any directions or instructions for the use of the video remote interpreting services or the numeric key code to open her office door posted at the nursing station for use of the service. She said she was not aware of any communication board for use for brief interactions or communication with Resident #1. On 6/17/26 at 3:00 PM, interview with the Activity Director revealed that she had not utilized the tablet and video remote interpreting services to facilitate communication with Resident #1 but was aware of its location. She said she had not received any training in using the tablet or the facility's translation service. She said she was not aware of any communication board for use for brief interactions or communication with Resident #1.On 6/17/26 at 3:50 PM, observation and interview with Resident #1 during which the State Agency (SA) was able to speak limited conversational Spanish, coupled with the use of cellular telephone for translation, was able to have a conversation with Resident #1, who was neat, clean, and free from malodorous smells. Her demeanor was pleasant, calm and welcoming. She was able to understand and answer simple questions in Spanish.On 6/17/26 at 4:45 PM, interview with CNA #4 revealed the scheduled CNAs rotated from hall to hall but that she had been assigned to the care of Resident #1 and familiar with her and her care. She stated that she was not aware of or received training regarding a device for translation/communication with Resident #1 until 6/17/26. She confirmed that she had never used the tablet for communication with Resident #1. On 6/18/26 at 12:14 PM, during a telephone interview, NP #1 reported that she visited Resident #1 routinely for assessment and was unaware of the video remote interpreting services and had not received any training related to the use of the service for communication with Resident #1. She confirmed that she observed the incident on 6/04/26 and that the CNA had not utilized the service or any communication or translation aide/device to communicate with the resident.On 6/18/26 at 2:10 PM, observation of Resident #1 with the SSD in the resident's room revealed the SSD utilized a tablet and video remote interpreting services to conduct a Minimum Data Set (MDS) assessment. The SSD began with the resident walking around the room, and the resident was not concentrating on the interview questions. After the SSD asked the translator to ask the resident to sit down, the resident did so and was more involved with the interview and although she was unable to answer some of the questions, she interacted with the SSD and translator much more. The SSD did not ever ask the translator to translate the resident's responses to her questions or what the resident had said when she spoke. SA speaks limited conversational Spanish and was able to understand some of the resident's responses and spontaneous remarks. Resident #1 was not asked by the SSD or translator if she needed or wanted an interpreter to communicate with a doctor or health care staff. When the SSD asked Resident #1 through the translator if she felt lonely or isolated, she confirmed that she did. She said she felt lonely at the facility. The resident was oriented to self and easily answered questions related to her vision, hearing and dental health. On 6/18/26 at 4:10 PM, during interview the DON confirmed that there was no communication board for use with Resident #1 and that while the facility had a device for communication with Resident #1 staff may not have been aware of it or how to use it. She stated that she was not sure if use of the device and communication aides would affect staff interactions with the resident or attempts at redirection during episodes of difficult behavior.On 6/18/26 at 4:30 PM during interview with the Administrator revealed he was not aware that nursing staff and health care providers were not utilizing the facility provided device for communication with Resident #1. He said that the facility would do what they needed to do to meet the needs of Resident #1, and all residents, including training staff in the use of the device and language service for communication with Resident #1.Record review of the Progress Note for Resident #1 revealed a Physician Progress Note dated 6/04/26 signed by Nurse Practitioner (NP) #1 documented observation of an incident in which Resident #1 was seen plundering through and taking the belongings of another resident that were out in the hallway and a CNA (unnamed) attempted to retrieve the belongings during which Resident #1 became combative with the CNA. Record review of the Progress Note for Resident #1 dated 6/16/26 at 9:04 PM revealed Licensed Practical Nurse (LPN) #1 documented Resident throwing things and hitting staff for redirecting her. On 6/19/26 at 1:41 PM, in a post exit interview, LPN#1 returned a telephone call to the SA and during the telephone interview reported that she was not aware of a device at the facility to facilitate communication through language translation for Resident #1 and had not received any training regarding the device. She confirmed that she was on duty on 6/16/26 when Resident #1 displayed combative behavior and struck staff attempting to redirect her. She stated that the staff attempting to redirect Resident #1 did not speak Spanish, did not attempt to use any communication aides or device, and had not contacted family to assist with communication. She stated that she did not know if use of translation service or communication aides would have had any impact on the resident's behavior or the interaction with staff. Record review of the admission Record for Resident #1, revealed the facility admitted the resident on 6/11/25 and the resident had diagnoses of senile degeneration of brain, dementia, Alzheimer's Disease, anxiety, restlessness and agitation.Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 3/20/26 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score as 0 which indicated severe cognitive impairment. The facility documented that the resident's preferred language was Spanish and that she needed or wanted an interpreter to communicate with a doctor or health care staff.

Based on observation, interview, and record review, the facility failed to ensure that residents were protected from a resident who was admitted with known aggressive behaviors and failed to provide adequate supervision and interventions for that resident. The facility admitted and continued to retain Resident #1 without ensuring appropriate psychiatric care, enhanced supervision, or reassignment of vulnerable roommates. This systemic failure directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4.The facility's failure to provide adequate supervision to prevent the exhibited aggressive and combative behaviors of Resident #1 placed this resident, and other residents at risk, in a situation that was likely to cause serious injury, harm, impairment, or death. The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to Resident #1's exhibited aggressive and combative behaviors and placed all residents who were admitted with at risk. This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 09/10/25.The IJ and SQC existed at: CFR 483.25(d)(1)(2) Free of Accidents Hazard/Supervision/Devices (F689) Scope and Severity (S/S) - JThe SA notified the facility's Administrator of the IJ and SQC on 10/17/2025 at 12:51 PM and provided the Administrator with the IJ templates.The facility submitted an acceptable removal plan on 10/17/25 in which the facility alleged all corrective actions were completed on 10/17/25 and the IJ was removed on 10/18/25, therefore, the scope and severity of 42 CFR S483.12(a)(1)Free from Abuse and Neglect (F600), was lowered to a scope and severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: On 10/16/25 at 12:38 PM, during an interview the Registered Nurse (RN) Unit Manager stated that Resident #1 was admitted on [DATE] and had such behaviors as refusing medications and threatening to harm staff. This escalated to him chasing her toward the nurse's station and cornering her against the wall. As a result, she contacted her Assistant Director of Nursing (ADON) and other administrative staff via group text. She requested that the resident be sent out because he could not be redirected. However, there were no beds available at the two behavioral centers they called, so Resident #1 had to stay at the facility until one became available. She revealed that the adjoining roommate, Resident #2, was fearful and not relocated. She indicates that while other nurses monitored Resident #2 during the day shift, she is unaware whether anyone watched the resident at night and acknowledges that it was not fair for residents to remain in fear.On 10/16/25 at 1:29 PM, during an interview the ADON stated that Resident #1 refused medications, at one point trapped his roommate by preventing staff entry, barricaded himself in another resident's room, slammed a fire extinguisher, and required police intervention. She stated his admission records indicated violent behavior, but at times he was calm.On 10/16/25 at 1:57 PM, during an interview the Director of Nursing (DON) confirmed the resident was discharged on 10/12/25. She explained that the admission records reflected paranoia and psychosis, but she was unaware of the extent of violent behaviors, acknowledged that the roommate or the adjoining resident was not relocated, and stated she would have moved them had she known the risk.On 10/16/25 at 12:10 PM, Licensed Practical Nurse (LPN) #1 reported that on 10/11/25 she observed the resident in the bathroom doorway holding a Bible and clippers saying, I'm going to kill you. She stated that she documented but did not notify supervisory nurses, and that the following day the resident again barricaded himself in the room, requiring police to be notified. She observed Resident #2, who resided in the adjoining room, crying on the smoking porch due to fear.On 10/16/25 at 3:32 PM, during an interview, LPN #2 reported Resident #1 paced at night, entered other residents' rooms, and yelled and threatened when redirected, and that Resident #2 was impacted as he avoided his room at times, and stayed in activities during the day, and refused to go to use the adjoining bathroom at night due to fear. LPN#2 stated that no interventions beyond verbal reassurance were implemented and that there was no relocation of the roommate because the resident was not aggressive all the time.On 10/16/25 at 11:02 AM, during an interview Resident #2 explained he had the adjoining room to Resident #1, who repeatedly entered through the shared bathroom, yelled, cursed, and threatened him with harm. He stated that he could not sleep and did not feel safe. He stated that staff were aware and attempted redirection for Resident #1 and that police ultimately intervened.On 10/16/25 at 11:46 AM, in an interview with Resident #4 stated that Resident #1 cursed and threatened to kill him. He stated that he activated the call light and that Resident #1 barricaded the door, preventing staff entry, and that the police removed the resident.On 10/16/25 at 11:55 AM, during an interview, Resident #3, who lives across the hall, reported being afraid to leave her room because the resident would yell and pace the halls at night.Record review of the Progress Notes dated 9/11/25 at 3:57 PM Resident #1 refused Haldol and accused the nurse of trying to kill him. Staff were unable to redirect him. Between 4:40 PM and 5:08 PM, he exhibited a series of escalating behaviors, including pacing, yelling profanities, threatening staff with harm, and charging at a nurse, with staff again unable to redirect or approach. Record review of the Progress Notes dated 9/14/25 at 11:53 PM, Resident #1 became agitated over the volume of the television, refused to wear his wander guard, and was up all-night disturbing others. Record review of the Progress Notes dated 10/10/25, at 7:04 PM, Resident #1made inappropriate sexual comments to a nurse, stating, You turning me on, and repeated the statement three times. Record review of the Progress Notes dated 10/11/25 at 1:36 PM, he made additional sexual comments and was observed touching himself inappropriately, which caused staff discomfort. Between 4:33 PM and 4:43 PM Resident #1 threatened to kill staff, ran hot water in an attempt to scald someone, tore up the window blinds, screamed threats at his roommate, threw shoe soles, refused to sleep, and played the television at an excessively high volume. Record review of the Progress Notes dated 10/12/25 between 1:44 PM and 3:46PM, Resident #1 demonstrated manic behavior, including yelling, slamming doors, speaking loudly, waking other residents, threatening staff, barricading rooms, throwing a fire extinguisher, and attempting to attack someone. From 4:05 PM to 7:26 PM, he continued to be aggressive, yelling, pushing furniture into a nurse, blocking doors, threatening his roommate, and ultimately requiring intervention from both police and emergency medical services. Between 10:29 PM and 12:00 AM, after returning from the emergency room, he refused to remain in his room, continued pacing, and required one-on-one supervision. From 12:00 AM to 4:30 PM, Resident #1 again threatened staff, barricaded another resident's room, and threw a fire extinguisher, prompting another call to police. Between 3:50 PM and 4:16 PM, Resident #1 remained combative, refused to have his vital signs taken, and triggered drug interaction alerts due to his antipsychotic medication regimen.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 9/9/25 with diagnoses including Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/25 revealed a Brief Interview for Mental Status (BIMS) score of five (5) indicating Resident #1 had severe cognitive impairment.Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 2/6/25 with diagnoses including Major Depressive Disorder.A record review of the quarterly MDS with an ARD of 8/16/25 revealed a BIMS score of (15) indicating the resident was cognitively intact. Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 9/15/25 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the MDS with an ARD of 9/21/25 revealed a BIMS score of (15) indicating the Resident #3 was cognitively intact.Resident #4A record review of the admission Record revealed the facility admitted Resident #4 on 9/28/23 with diagnoses including Hemiplegia and Hemiparesis affecting the right non-dominant side.A record review of the annual MDS with an ARD of 9/26/25 revealed a BIMS score of (14) indicating the Resident #4 was cognitively intact. Removal Plan: Facility failed to provide adequate supervision to protect Residents from a known safety hazard caused by Resident # 1 with a documented history of aggression and violence. Staff failed to implement continuous monitoring, relocate roommates, or remove environmental risks after the Resident repeatedly barricaded rooms, made death threats, and threw a fire extinguisher.10/12/25 at 6:46 AM Resident #1's physician and Resident Representative was notified by the Licensed Nurse #1 of Resident barricading himself in his room by pushing the bed against the door and threatening staff verbally and physically. Licensed Practical Nurse (LPN) 1 then called 911 emergency services. Local police were dispatched and arrived at the facility at 7:06 AM. Ambulance arrived at approximately 7:37 AM and transported Resident #1 to local Emergency Department. Emergency department notified Director of Nursing (DON) at 11:05 AM requesting that Resident #1 be picked up from Emergency Department. Resident #1 was transported back to facility-by-facility staff and arrived back at 12:00 PM. Resident #1 was placed in a private room upon return and placed on one-on-one supervision. Resident continued pacing threatening staff and threw the extinguisher to ground. At 2:30 PM Resident #1 barricaded the door to another Residents room. Staff notified police and ambulance service. Resident # 1's physician was notified, and physician orders noted for Haldol 5 mg Intramuscular every six (6) hours as needed for psychosis related to Schizophrenia. Ambulance arrived and Resident # 1 was transported to the local emergency department a second time. Resident #1 was transported from the Emergency Department to the inpatient behavioral health facility. Resident # 1 remains in inpatient behavioral health facility.Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk was removed.On 10/12/25 the Executive Director interviewed Resident that was barricaded in room with Resident # 1 and asked if he was ok and was, he was afraid. Resident indicated that he was not afraid.On 10/13/25 facility issued an emergency notification of discharge to residents' family at 10: 13 AM. Social Services Director began searching for alternative placement. Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.Education was initiated with all facility staff on 10/16/25 by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.Education was conducted on 10/16/25 with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing on 10/16/25 and 10/17/25 to assess for any psychosocial harm or Incident of trauma.On 10/17/25 Residents #2, #3 and #4's Care Plans were updated to Include Trauma Centered care.Quality Assurance Performance Improvement (QAPI) Committee met on 10/17/25 at 2:00 PM. Attendees were the Medical Director, Executive Director, Director of Nursing, Social Services Director, Minimum Data Set Nurse, Unit Manager, Business Development, Regional Director of Nursing, Medical R cords Clerk, Assistant Director of Nursing, Treatment Nurse, Infection Control Preventionist, Maintenance Director and Human Resources Director. Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.The facility alleges all corrective actions were completed on 10/17/25 and the Immediate Jeopardy was removed on 10/18/25.Corrective Actions:The Director of Nursing started an all-staff in-service on Abuse/ Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm that concluded 10/20/25. Affected residents care plans were updated on 10/16/25 to reflect trauma informed care by the Care Plan team.The Regional Director in-serviced the Administrator and the Director of Nursing on 10/17/25 regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.An Emergency Quality Assurance Committee was held on 10/17/25 with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.The facility completed all actions to remove the Immediate Jeopardies on 10/17/25 and alleges the IJ was removed on 10/18/25. On 10/20/25, the State Agency (SA) validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 10/18/25.

Based on observation, interview, record review and facility policy review, the facility failed to ensure that residents were free from abuse, neglect, and intimidation when it admitted and retained a resident with known aggressive and violent behaviors (Resident #1) without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The facility's failure to provide necessary psychiatric intervention or to relocate vulnerable roommates placed residents at risk for serious injury, harm, impairment, or death, resulting in an immediate jeopardy to resident health and safety. This deficient practice directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4.The facility failed to ensure that residents were free from abuse and neglect when it did not provide adequate supervision or implement effective interventions to prevent the ongoing aggressive and combative behaviors of Resident #1. This failure resulted in an unsafe environment and placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. During the investigation of the complaint, the SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/10/25 and existed at:42 CFR S483.12(a)(1) Free from Abuse and Neglect (F600) - Scope/Severity (S/S) of JThe SA notified the facility's Administrator of the IJ and SQC on 10/17/2025 at 12:51 PM and provided the Administrator with the IJ templates.The facility submitted an acceptable removal plan on 10/17/25 in which the facility alleged all corrective actions were completed on 10/17/25 and the IJ was removed on 10/18/25, therefore, the scope and severity of 42 CFR S483.12(a)(1)Free from Abuse and Neglect (F600), was lowered to a scope and severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference: F689Findings include:A record review of the Abuse, Neglect and Exploitation Policy with implementation date of 6/1/25 revealed, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. IV. Identification of Abuse. Possible indicators of abuse include, but are not limited to: 1. Resident or staff report of abuse. 5. Verbal Abuse. 7. Psychological abuse of a resident observed. 10. Sudden or unexplained changes in behaviors and/or activities, such as fear of a person.At 11:03 AM, on 10/16/25, in an interview with Resident #2, who shares an adjoining room with Resident #1, he revealed that there were multiple times when Resident #1 would come through their adjoining bathroom door and yell at him while he was in bed at night, cussing and making threats that he was going to harm him. He said he could not sleep while that man was next door. He stated that he simply did not feel safe while Resident #1 was staying next door. He indicated that all staff were aware of what was happening and were attempting to calm Resident #1 and prevent him from entering his room. At 11:46 AM, on 10/16/25, in an interview with Resident #1's roommate, who is Resident #4 explained that Resident #1 cursed at him, called him names, and made threats, stating he was going to kill him. However, these incidents did not occur frequently. When he pressed the call light, the staff would come and try to calm Resident #1 down. The most recent time was when they tried to calm Resident #1, but he barricaded them in the room, preventing anyone from coming in.At 11:55 AM, in an interview with Resident #3, who is in a room across the hall from Resident #1, revealed that she was afraid of Resident #1 and would not come out of her room when he was yelling in the halls.At 12:10 PM, on 10/16/25, in an interview with Licensed Practical Nurse (LPN) #1, she revealed that on Sunday, 10/12/25, during the 1:30 PM smoke break, she observed Resident #2 crying and saying, That boy down there, out of frustration and because he was tired of him being there. During an interview with the Registered Nurse (RN) Unit Manager at 12:38 PM, on 10/16/25, the resident explained Resident #1's initial behaviors, which started when he first admitted , when his medication nurse reported to her that the resident was refusing to take medications, taking medications off her cart, and making it difficult for her to pass meds. When she went to investigate, she found him standing in the doorway of his room. She attempted to give him his medicine, but he refused and walked down the hall, threatening to kill everyone. At that point, she still did not identify him as a danger to himself or the residents. A few days later, she reported that he chased her back to the nurse's station and cornered her. She indicates that it was during that incident that she contacted her Assistant Director of Nursing (ADON), who was in her office at the time, via text to inform her and the Director of Nursing (DON) about what had happened, stating that he needed to be sent out due to uncontrollable aggressive behaviors. She went on to say that during this time, Resident #2 was very afraid of Resident #1 and wouldn't go to the bathroom because it adjoined Resident #1's bathroom. To ease him, she and the other nurses watched Resident #2 and assured him they would protect him. However, she was unsure whether anyone monitored the resident at night to ensure his safety. She indicates that during all of this, neither Resident #2 nor Resident #4 was moved to another room. She admits that it is unfair for residents to be in an environment where they had to fear another resident attacking them. On 10/16/25 at 1:29 PM, in an interview with the ADON, she revealed that Resident #1 prevented nurses from checking on him and his roommate, which meant the roommate could not receive his medication. She said this was not the first time Resident #1 had done this. She stated he would go into other rooms and prevent staff from entering. She confirmed that Resident #2 was afraid to use the adjoining bathroom and is not aware of any interventions in place for him during those times.In a follow-up interview with the DON at 3:02 PM, on 10/16/25, she revealed that the staff's first attempt to send the resident out was on 9/11/25, but they were not successful until 9/23/25. At 3:32 PM, on 10/16/25, LPN #2, who serves as the medication nurse, recalled that Resident #2 was the most affected by Resident #1's behaviors. At times, he was afraid to go into his room because Resident #1 was next door, so he spent more time in activities to be around others. She said no formal interventions were put in place other than verbally trying to comfort Resident #2, such as telling him everything would be ok. Record review of the Progress Notes dated 9/11/25 at 3:57 PM Resident #1 refused Haldol and accused the nurse of trying to kill him. Staff were unable to redirect him. Between 4:40 PM and 5:08 PM, he exhibited a series of escalating behaviors, including pacing, yelling profanities, threatening staff with harm, and charging at a nurse, with staff again unable to redirect or approach. Record review of the Progress Notes dated 9/14/25 at 11:53 PM, Resident #1 became agitated over the volume of the television, refused to wear his wander guard, and was up all-night disturbing others. Record review of the Progress Notes dated 10/10/25, at 7:04 PM, Resident #1 made inappropriate sexual comments to a nurse, stating, You turning me on, and repeated the statement three times. Record review of the Progress Notes dated 10/11/25 at 1:36 PM, he made additional sexual comments and was observed touching himself inappropriately, which caused staff discomfort. Between 4:33 PM and 4:43 PM Resident #1 threatened to kill staff, ran hot water in an attempt to scald someone, tore up the window blinds, screamed threats at his roommate, threw shoe soles, refused to sleep, and played the television at an excessively high volume. Record review of the Progress Notes dated 10/12/25 at 7:37 AM, Resident #1 was transferred to the hospital after Resident #1 continued to exhibit behaviors including manic behavior, including yelling, slamming doors, speaking loudly, waking other residents, threatening staff, and attempting to attack someone. Resident #1 continued to be aggressive, yelling, pushing furniture into a nurse, blocking doors, threatening his roommate, and ultimately requiring intervention from both police and emergency medical services. Record review of the Progress Notes dated 10/12/25 at 12:00 PM, revealed Resident #1 returned to the facility. After returning from the emergency room, he refused to remain in his room, continued pacing, and required one-on-one supervision. Resident #1 remained combative, refused to have his vital signs taken. At 2:30 PM documentation revealed Resident #1 again threatened staff, barricaded another resident's room, and threw a fire extinguisher, prompting another call to police. Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 9/9/25 with diagnoses including Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/25 revealed a Brief Interview Mental Score (BIMS) score of five (5) indicating Resident #1 had severe cognitive impairment.Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 2/6/25 with diagnoses including Major Depressive Disorder.A record review of the quarterly MDS with an ARD of 8/16/25 revealed a BIMS score of (15) indicating the resident was cognitively intact. Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 9/15/25 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the MDS with an ARD of 9/21/25 revealed a BIMS score of (15) indicating the Resident #3 was cognitively intact.Resident #4A record review of the admission Record revealed the facility admitted Resident #4 on 9/28/23 with diagnoses including Hemiplegia and Hemiparesis affecting the Right Non-Dominant Side.A record review of the annual MDS with an ARD of 9/26/25 revealed a BIMS score of (14) indicating the Resident #4 was cognitively intact.Removal Plan:Facility failed to provide adequate supervision to protect Residents from a known safety hazard caused by Resident # 1 with a documented history of aggression and violence. Staff failed to implement continuous monitoring, relocate roommates, or remove environmental risks after the Resident repeatedly barricaded rooms, made death threats, and threw a fire extinguisher.10/12/25 at 6:46 AM Resident #1's physician and Resident Representative was notified by the Licensed Nurse #1 of Resident barricading himself in his room by pushing the bed against the door and threatening staff verbally and physically. Licensed Practical Nurse (LPN) 1 then called 911 emergency services. Local police were dispatched and arrived at the facility at 7:06 AM. Ambulance arrived at approximately 7:37 AM and transported Resident #1 to local Emergency Department. Emergency department notified Director of Nursing (DON) at 11: O5 AM requesting that Resident #1 be picked up from Emergency Department. Resident #1 was transported back to facility-by-facility staff and arrived back at 12:00 PM. Resident #1 was placed in a private room upon return and placed on one-on-one supervision. Resident continued pacing threatening staff and threw the extinguisher to ground. At 2:30 PM Resident #1 barricaded the door to another Residents room. Staff notified police and ambulance service. Resident # 1's physician was notified, and physician orders noted for Haldol 5 mg Intramuscular every six (6) hours as needed for psychosis related to Schizophrenia. Ambulance arrived and Resident # 1 was transported to the local emergency department a second time. Resident #1 was transported from the Emergency Department to the inpatient behavioral health facility. Resident # 1 remains in inpatient behavioral health facility.Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk was removed.On 10/12/25 the Executive Director interviewed Resident that was barricaded in room with Resident # 1 and asked if he was ok and was, he was afraid. Resident indicated that he was not afraid.On 10/13/25 facility issued an emergency notification of discharge to residents' family at 10: 13 AM. Social Services Director began searching for alternative placement. Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.Education was initiated with all facility staff on 10/16/25 by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.Education was conducted on 10/16/25 with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing on 10/16/25 and 10/17/25 to assess for any psychosocial harm or Incident of trauma.On 10/17/25 Residents #2, #3 and #4's Care Plans were updated to Include Trauma Centered care.Quality Assurance Performance Improvement (QAPI) Committee met on 10/17/25 at 2:00 PM. Attendees were the Medical Director, Executive Director, Director of Nursing, Social Services Director, Minimum Data Set Nurse, Unit Manager, Business Development, Regional Director of Nursing, Medical R cords Clerk, Assistant Director of Nursing, Treatment Nurse, Infection Control Preventionist, Maintenance Director and Human Resources Director. Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.The facility alleges all corrective actions were completed on 10/17/25 and the Immediate Jeopardy was removed on 10/18/25.Corrective Actions:The Director of Nursing started an all-staff in-service on Abuse/ Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm that concluded 10/20/25. Affected residents care plans were updated on 10/16/25 to reflect trauma informed care by the Care Plan team.The Regional Director in-serviced the Administrator and the Director of Nursing on 10/17/25 regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.An Emergency Quality Assurance Committee was held on 10/17/25 with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.The facility completed all actions to remove the Immediate Jeopardies on 10/17/25 and alleges the IJ was removed on 10/18/25. On 10/20/25, the State Agency (SA) validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 10/18/25.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision and implement effective elopement prevention strategies for one (1) of four (4) sampled residents (Resident #1), who had a known cognitive impairment and elopement risk, resulting in an incident of elopement.The facility's failure to ensure supervision and implement interventions-including failure to detect the resident's absence promptly, and failure to secure exit doors-resulted in Resident #1 exiting the facility through the front entrance without staff knowledge and being unsupervised in the community for approximately one (1) hour and twenty-nine (29) minutes. The resident was found approximately two (2) miles away at a local business after receiving a ride from an unknown individual. This failure placed Resident #1 in a situation that was likely to cause serious injury, serious harm, serious impairment, or death, given the resident's severe cognitive impairment, multiple medical diagnoses, and the environmental risks encountered during elopement (e.g., traffic, extreme heat, lack of supervision).The facility's failure to ensure supervision and implement interventions for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death.This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 08/07/2025, when Resident #1 exited the facility unsupervised and without authorization. The State Agency (SA) notified the Administrator of the Immediate Jeopardy on 08/11/2025 at 4:15 PM and provided an IJ Template.The State Agency (SA) validated the Corrective Action Plan on 8/13/25 and determined that the IJ was removed on 8/9/25, prior to exit. Findings include:Record review of the facility policy titled, Missing Patient/Resident with Revision Date 8/01/2020 revealed, OVERVIEW: Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Record review of the facility policy Accident and incident Investigation with Effective Date 11/30/2014 revealed, Policy: Certain Accidents and Incidents.will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. Record review of the facility policy Elopement/Wandering Risk Guideline with Revision Date 8/01/2020 revealed, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions.Record review of the Incident Report dated 8/07/25 revealed documentation of the elopement and return without injury of Resident #1 on 8/07/25.Record review of the facility Verification of Investigation dated 8/07/25 revealed on 8/7/25 at 11:10 AM the nurse discovered Resident #1 was unable to be located. Facility staff called a Code Yellow and searched for the resident. The local police department and the Resident Representative (RR) were notified. At 11:53 AM the local police department notified the facility the resident had been found. At 12:05 PM, the Resident returned to the facility and was assessed by the Nurse Practitioner with no injury noted. On 8/11/25 at 10:10 AM, during a record review of the Facility Investigation and Incident Report both dated 8/7/25 and an interview with the Administrator and the Director of Nursing (DON), revealed the DON reported that the elopement of Resident #1 was discovered when Licensed Practical Nurse (LPN) #1 realized she no longer saw the resident sitting in the lobby where he had been last observed at or around 10:30 AM. The DON reported that she was on D Hall at approximately 10:45 AM when LPN #1 reported to her that she was unable to locate Resident #1. The DON immediately notified the Administrator at approximately 11:10 AM. At approximately 11:15 AM the DON notified the Administrator and called a CODE YELLOW using the overhead public announcement (PA) system. They reported that the resident was last seen seated in a chair in the lobby facing the reception desk and main entrance at approximately 10:30 AM in the lobby across from the front door. The DON and Administrator both said that in separate interviews with the resident upon return to the facility he had told them that he left the facility through the front door when visitors were coming in/going out. The Administrator and DON both confirmed that the resident was last observed in the facility at approximately 10:30 AM and was out of the facility unattended by staff for approximately one hour and twenty-nine minutes when he was observed at a local laundromat two (2) miles from the facility with no obvious injury. They explained that the system of how staff was made aware of a missing resident included word of mouth and Code Yellow announced over the overhead PA system. They explained that they call the alert anytime a resident couldn't be located and hadn't signed out using the alert, Code Yellow which was called at 11:20 AM on 8/07/25. The Administrator confirmed the report by the DON that the Administrator had been notified of a missing resident at 11:15 AM on 8/07/25 after the DON was notified at approximately 11:10 AM, and the Resident Representative for Resident #1 was called at 11:24 AM but the telephone number was out of service and the DON called the resident's daughter at 11:26 AM, and the NP for the resident's physician was notified at 11:20 AM. The DON said that she had conducted a body audit and found no injuries and the NP completed an assessment and noted no injuries and the resident was not transferred to the hospital. They said the immediate response of the facility was that the staff searched for resident, the resident was returned to the facility via Unit Manager, the NP was present at the facility upon the resident's return and assessed resident, which included a Body Audit, and finally one-on-one supervision was provided for Resident #1 for 48 hours and a wander guard anklet was applied to the resident's ankle immediately. The DON and Administrator said the police were notified, but during interview in the Administrator's office, The Unit Manager notified the resident had been located and was in route back to the facility at 11:46 AM, so they were not sure if a police report was written or not. The DON reported that elopement was reported to the State Agency on 8/07/25 at 1:28 PM. They reported that the Maintenance Supervisor checked the security of the doors at 1:00 PM on 8/07/25 as well as every day shift, Monday through Friday, and the residents' wander guard units were checked by the nurses as well as each night. The DON reported that she conducted Missing Resident/Elopement Drills every three months (quarterly) by DON in accordance with facility policy. The DON reported that In-Service Training for all staff was started on 8/07/25. The DON confirmed that the facility did routine audits to ensure elopement books and daily care guides were accurate. The Administrator and DON confirmed that a Census Audit was conducted, and the presence of all other residents not signed out was confirmed via direct observation by the nursing staff. The DON and record review of the Care Plan for Resident #1 revealed that Resident #1's care plan was revised/updated after the elopement on 8/7/25.On 8/11/25, the SA attempted multiple times to contact the RR and Contact #1 for Resident #1 without success and no mechanism to leave a message. On 8/13/25 during a telephone interview with Contact #1 for Resident #1, his family member confirmed that the facility had notified her on 8/07/25 that Resident #1 had eloped and that he had been returned to the facility.On 8/11/25 at 10:25 AM, observation and an interview with Resident #1 in his room revealed Resident #1 stated that he was from a nearby town where his family lived, approximately twenty-five miles away. He confirmed that he had eye surgery which had greatly improved his vision. He stated that he was able to get himself up and walk with his cane but used his wheelchair for longer distances. He said he remembered on 8/07/25 going out the front main entrance and getting a ride with a man in a truck to a nearby avenue. He stated that his ultimate goal was to get to his former residence. He said that the man in the truck dropped him off at the local business and that facility staff had shown up and given him a ride back to the facility. Observation revealed the resident had a wander guard safe wandering device on his left ankle. On 8/11/25 at 10:45 AM, during an interview LPN #1 stated she observed Resident #1 walking with a walker, and that he had taken a seat in the lobby across from the reception desk and main front entrance at approximately 10:00 AM wearing a black sock cap, a short-sleeved button up shirt, a pair of blue jeans and slide on shoes, holding his cane. She stated that at approximately 10:50 AM, she had begun to look for him and he was no longer sitting in the lobby, nor was he in the dining room or common areas and was not in his room. She said that after looking in those areas, at approximately 11:00 AM she notified the DON that she could not locate the resident, the DON called a Code Yellow over the PA system and staff continued to look inside and outside for the resident. She reported that notifications were made to the resident's primary healthcare provider (PHP), Contact #1 and local police department (PD). She stated that the PD sent out an officer but that shortly after the officer arrived, RN #1 (Unit Manager) notified the DON that she (RN #1) had located the resident and had him in her supervision and was returning to the facility with him. She stated that the PHP was present at the facility upon his return so Registered Nurse (RN) #1 and the PHP conducted assessment including body audit and identified no injuries and the resident's vital signs were all within normal limits. She stated she had not observed any change in physical or psychosocial condition since the elopement. She stated that the weather was clear and hot on 8/07/25. She stated that during the missing resident procedure, CNA #1 had reported to her that she (CNA #1) had last seen Resident #1 in the facility at approximately 10:45 AM in the lobby and noted no agitation or unusual behavior. LPN #1 reported that upon return to the facility at 11:59 AM the resident was immediately placed on one-on-one supervision for forty-eight (48) hours, and a safe wandering device was applied to his left ankle and tested for proper functioning. She confirmed that on 8/07/25 the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25. LPN #1 stated that Resident #1 had never displayed exit seeking behavior prior to 8/07/25. On 8/11/25 at 11:00 AM, an interview with the facility Receptionist revealed she recalled that on 8/07/25 at approximately 11:10 AM, Resident #1 had approached the sliding glass window of her office walking with his cane and expressed that he needed to go home and see his family. She stated that he had developed a habit of visiting the Reception Desk and requesting cash and that he was usually in his wheelchair. She said she asked him to take a seat as she was busy with cash disbursements, answering telephone calls and granting entrance and exit for staff, contractors and visitors. She stated that she had not observed him get up or leave the lobby. She confirmed that the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25. On 8/11/25 at 11:10 AM, observation revealed all parking spaces in the well-maintained facility parking lot surfaced with asphalt. Observation revealed the route to the location where Resident #1 was located lead through a well populated residential area, over a bridge that was over a railroad track and led to a four-lane avenue with a speed limit of thirty-five (35) miles per hour, with repaving in progress and several traffic lights and pedestrian walkways; the location was equal distance between two traffic lights. The location where the resident was located by RN # 1, was a local business with a deep parking lot surfaced with well-maintained concrete, four occupied parking spaces and five unoccupied and one main entrance. The SA observed one hundred fifty (150) cars traveling the avenue in front of the location in a five-minute period.Review of weather history for the locale for 8/07/25 per world wide web national weather service revealed that on 8/07/25 at 11:53 AM the temperature was eighty-nine (89) degrees Fahrenheit with six (6) mile per hour winds and zero (0) precipitation and conditions were partly cloudy. On 8/11/25 at 1:10 PM, an interview revealed RN #1 she observed Resident #1 sitting in the lobby at around 11:10 AM time when she left going to the hospital to take a sample to the laboratory. She stated that returning to the facility she was driving west on the boulevard and observed the resident wearing a black knitted hat, short-sleeved button-up shirt, slide on shoes and carrying a cane walking through the parking lot of a local business in a parking space near the business' door. She stated she had parked her car near the front door, got out and assisted the resident without resistance into the backseat of her car. She described the weather as partly cloudy and hot. She reported that during the drive back to the facility the resident told her that he exited the facility through the front door and got a ride with a man in a truck to the location where she located him. RN #1 confirmed that the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25.On 8/11/25 at 4:05 PM interview with CNA #1 revealed she said was working dayshift on D Hall on 8/07/25 and was assigned to the care of Resident #1. She said she had observed him sitting in a chair holding his cane in the front lobby across from the front office and front entrance at approximately 8:45 AM. She reported that at approximately 11:15 AM she did not observe the resident anymore until he returned from elopement.Record review of the Ad Hoc Quality Assurance and Performance Improvement (QAPI) dated 8/08/25 with attached sign-in sheet revealed confirmed that the facility conducted a QAPI committee meeting attended by the Medical Director, DON, Infection Preventionist (IP) and other key personnel/department directors. The agenda included the elopement of Resident #1 on 8/07/25 with a plan for the prevention with corrective actions included. Record review of the Education In-Service Attendance Record dated 8/07/25 with attached sign in sheet confirmed the facility provided in-service training for all staff regarding the facility elopement policy and procedure for missing residents and missing resident procedure experience. Record review of the Education In-Service Attendance Record dated 8/07/25 with attached sign in sheet confirmed the facility provided in-service training for all staff regarding visualization of the door until it is clear and closed and locked when granting admission/egress and abuse and neglect prevention and reporting. Record review of the admission Record for Resident #1revealed the facility admitted the resident on 9/27/24 and the resident had diagnoses of osteoarthritis, hypertension, vision loss, and atherosclerotic heart disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 7/4/25 revealed Resident #1 had a Brief interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Section B indicated the facility had assessed the resident having severely impaired vision and Section GG indicated that he relied on a wheelchair for mobility. Corrective Action Plan:Brief Summary of Events:On 8/11/25 at 4:15 PM the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy Past Noncompliance related to F 689 Free of Accident Hazards /Supervision /Devices.Resident #1 at approximately 10:30 am left out the front entrance door and exited facility without staff knowledge. Resident #1 was located at 11:56 am approximately 2.0 miles from facility by Licensed Nurse #1 who returned the resident to the facility where he was assessed by nursing staff and his primary healthcare provided with no injuries noted and he was fitted with a safe wandering device.Immediate Action was initiated on 8/7/25: At approximately 11:05 AM Licensed Practical Nurse (LPN) #1 and Certified Nurse's Aide (CNA) #1 performed cursory search for resident #1. At 11:10 AM LPN #1 notified Director of Nursing (DON) that Resident #1 could not be located and the DON notified the Executive Director (ED) at approximately 11:15 AM. At 11:15 AM DON announced Code Yellow using the overhead public announcement (PA) system, for missing resident was called, and staff were dispersed to search inside and outside for Resident #1. At 11: 14 100% audit completed by Unit Manager #1 and Wound Care to ensure all residents were in the facility and accounted for. At 11:20 AM Nurse Practitioner (NP) #1 and Resident's Physician were notified of elopement. At 11:26 AM Resident #1's Contact (daughter) was notified of elopement. At 11:46 AM the DON notified the local police department of the missing resident. At 11:48 AM neighboring police department was notified of Resident #1 home address for a well check. At 11:56 AM Registered Nurse (RN) 1 located Resident #1 approximately 2.5 miles from facility at 11:59 AM and transported Resident #1 back to the facility and arrived at 12:05 PM. At 12:05 PM NP #1 assessed Resident #1 with no injury noted. A body audit was completed. LPN #1 conducted a body audit with no noted injury. Resident #1 was interviewed by the DON and ED. Resident #1 stated he had exited the facility through the front door and an older man in a truck gave me a ride . The facility initiated one-on-one supervision for Resident #1 for forty-eight (48) hours. Social Services Director SSD) assessed Resident #1 for psychosocial distress and noted none and completed a new Brief Interview for Mental Status (BIMS) assessment. At 12:30 PM Director of Nursing obtained an order for Resident #1 to have a secure care bracelet placed and LPN #1 applied secure care bracelet to Resident #1's Left ankle. The Minimum Data Set (MDS) Nurse updated the Care Plan for Resident #1. At 1:00 PM the Maintenance Director checked all the exit doors and ensured they were closed and locked. At 1:28 PM the ED notified the State Ombudsman. At 1:28 PM DON called the State Agency (SA) hotline and reported the elopement. At 2:30PM the ED placed signage on door that reminded visitors and staff to ensure door was completely closed when entering and leaving. A sign was also placed on the front desk by the visitors' sign in book. At 2:45 PM SSD was notified of need to send out letter to families to re-educate them on the importance of out-on-pass and sign-out procedures, not escorting residents outside of the facility without a staff member present, and encourage them to notify a staff member immediately, if a resident was attempting to leave the facility unattended by staff. At 4:19 PM DON completed the complaint e-form for the Mississippi State Attorney General. At 5:00 PM Nurse Managers completed a 100% audit of all residents for elopement risk, checked orders for secure care bracelets, made sure care plans were in place, and assessed residents to ensure those who are elopement risk had secure care bracelets in place and working by testing with handheld Secure Care Tester 135. SSD created information cards that were placed in the front office with a picture of the residents who are at risk for elopement and updated elopement binders placed at the nurse's stations and front desk. On 8/7/25 DON initiated Quality Observation, Monitoring of visitor's entry and exits to ensure Resident's do not leave out of the facility without staff knowledge. This will be done 2 times a day, during receptionist hours, 5 days a week, times 3 months per ADON/Designee. Quality Assurance Performance Committee (QAPI) met on 8/7/25 at 2:00 PM to review the events of Resident #1's exit from facility and determine a Root Cause. Attendees were Executive Director (ED), Social Services Director (SSD), Business Office Manager (BOM), Director of Nursing (DON), Activities Director (AD), Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) #1 and Medical Records Clerk (MRC) and IP. The Root Cause was determined to be that Resident #1 exited door when a visitor was entering.Education:On 8/7/25 and 8/8/25, In-Service education was conducted by the Director of Clinical Services on Elopement Policy, Procedure for Missing Resident , and emphasis on ensuring complete closure of door when letting visitors in/out. This was a 100% mandatory education, and all employees will receive training upon hire and prior to taking assignment.The Facility alleges all corrective actions were completed on 8/8/2025 and the immediate jeopardy was removed on 8/9/2025, prior to the State Agency entrance on 8/11/2025.On 8/13/25 the SA validated through observation, interview and record review that the facility had completed all corrective actions on 8/8/2025 and the Immediate Jeopardy was removed on 8/9/2025, prior to the State Agency entrance on 8/11/2025.

Based on observation, interviews, record review, and policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by improper hand hygiene practices and wound care for three (3) of six (6) direct care observations. (Resident #3, Resident #64 and #66) Findings included: Record review of the facility's Handwashing Hand Hygiene policy, revised August 2019 revealed Policy Statement The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use . Record review of the facility's policy titled Dressing, Dry Clean, revised September 2013, revealed, . Steps in the Procedure .15. Cleanse the wound with the ordered cleaner. If using gauze, use a clean gauze for each cleaning stroke. Clean from the least contaminated to the most contaminated area (usually, from the center outward). 16. Use a dry gauze to pat dry . Resident #3 On 1/6/2025 at 11:00 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 both entered the room, applied gloves, and began perineal care for Resident #3 without performing hand hygiene prior to applying clean gloves. CNA #1 pulled six (6) premoistened wipes from the packet and began cleaning the perineal area. When she ran out of wipes, she retrieved additional wipes from the packet twice with unclean gloves, touching the outside of the wipe packet during care. On 1/6/2025 at 11:29 AM, during an interview, CNA #1 confirmed that she forgot to wash her hands before starting care on Resident #3. She acknowledged that her actions could cause infection for the resident and that her failure to remove all needed wipes before starting care was an infection control issue, as she had touched the container with unclean gloves. On 1/6/2025 at 11:32 AM, during an interview, CNA #2 confirmed that she forgot to wash her hands before beginning perineal care for Resident #3. She confirmed her actions were an infection control issue. On 1/7/2025 at 12:52 PM, during an interview, Registered Nurse (RN) #1 stated the CNAs should have washed their hands before providing perineal care for Resident #3. She explained that CNA #1 should not have retrieved additional wipes with dirty gloves. RN #1 stated the CNAs caused cross-contamination and risked the spread of infection. On 1/7/2025 at 1:07 PM, during an interview, the Director of Nursing (DON) confirmed that the CNAs actions represented an infection control issue. She emphasized that staff must wash their hands prior to care, when transitioning from dirty to clean tasks, and after care. She added that failure to follow these practices could result in the spread of infections A record review of the Admission Record revealed the facility admitted Resident #3 on 1/22/2024 with diagnoses including Primary Generalized (Osteo) Arthritis and Cognitive Communication Deficit. A record review of Resident # 3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/25/24 revealed a Brief Interview for Mental Status (BIMS) of 03 indicating the resident was severely cognitively impaired. Section GG indicated the resident was dependent for toileting hygiene. Resident #64 On 1/8/2025 at 12:03 PM, during an observation, Registered Nurse (RN) #2 was observed providing wound care to Resident #64. RN #2 washed her hands and applied gloves. She removed a soiled dressing from the resident's right heel, did not change her gloves and then cleaned the wound. While cleaning the wound she used normal saline and a gauze in a circular motion five times, alternating between dirty to clean and clean to dirty without changing the gauze. She removed a heavily soiled dressing from the sacral area and placed it in a biohazard bag. She then cleaned the sacral wound in the same circular motion six times with the same gauze, again alternating between dirty to clean and clean to dirty and did not pat dry after cleaning as indicated in the physicians order. On 1/8/2025 at 2:20 PM, during an interview, RN #2 confirmed that she should have performed hand hygiene and applied clean gloves after removing the soiled dressing. She also confirmed that she should not have cleaned the wound in a circular motion multiple times with the same gauze. She acknowledged that her actions could increase the risk of infection and delay wound healing. A record review of Resident #64's Order Listing Report revealed a physician order dated 12/7/2024, Wound care: Cleanse stage IV (4) pressure ulcer to sacrum with Dakins, pat dry with 4x4 gauze. Apply silver alginate to the wound bed, and cover with bordered gauze daily and prn (as needed.) Physician orders dated 12/13/2024 revealed Wound care to Stage II (2) ulcer to R (right) heel with NS (normal saline), apply medi honey to the wound bed, cover with an ABD (abdominal) pad, and wrap with Kerlix. Changed daily and PRN (as needed.) A record review of the Admission Record revealed the facility admitted Resident #64 on 1/24/2024 with diagnoses including Pressure Ulcer of the Right Heel, Stage 2 and Pressure Ulcer of the Sacral Region, Stage 4. A record review of the MDS with an ARD of 11/28/2024 revealed Resident #64 was severely impaired for cognitive skills for daily decision making. Resident # 66 An observation and interview on 01/08/25 at 10:59 AM, with RN #2 performing wound care on Resident #66 revealed that she donned clean gloves without performing hand hygiene prior to removing and performing wound care to the resident's right knee abrasion. Upon finishing this wound, she rolled resident to his right side, removed a dressing with a moderate amount of foul-smelling purulent discharge on a sacral unstageable pressure ulcer with the same gloves used to dress and undress the first wound. She then walked to the resident's door, turned open the doorknob with the soiled gloves. An interview with RN #2 confirmed that she had not changed gloves or performed hand hygiene throughout the two procedures and that she opened the door with unclean gloves. She confirmed that infection could be spread from one wound to the other making it harder to heal and that wearing gloves to open the door could spread infection. An interview on 01/09/25 at 11:50 AM, with the DON confirmed that hand hygiene should be performed before and after completing wound care and before and after removing gloves. She confirmed that not doing this put the resident at risk of infection as well as increased difficulty in wound healing. She also confirmed that gloves should have been removed before touching a doorknob as that could increase the spread of infection throughout the facility. She further stated that it was her expectation that wound care would be performed according to guidelines for infection control and prevention. Record review of Admission Record revealed the facility admitted Resident #66 on 02/23/23 with medical diagnoses that included Pressure Ulcer of Sacral Region Unstageable. Record review of Resident #66's MDS with an ARD of 10/19/24 revealed Section M revealed the resident has 2 pressure ulcers. 50751

Based on observation, interviews, record review, and facility policy review, the facility failed to provide palatable, appropriately temperature-controlled foods for one (1) of (43) sampled residents. Resident #40 Findings included: A review of the facility's policy titled Food Quality and Palatability Policy (HCSG Policy 006), revised February 2023, revealed, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet the residents' needs . During an interview on 1/7/2025 at 11:19 AM, Resident #40 complained the food served was usually cold. An observation and interview on 1/7/2025 at 12:09 PM, a meal tray was provided, and temperatures were evaluated by the Dietary Manager. The temperatures were as follows: white rice, 122 F (Fahrenheit); spinach, 122 F; and egg noodles with gravy, 109 F. A sampling of the meal tray revealed that the food was bland and not served at a palatable temperature. During an interview at this time the Dietary Manager agreed that these temperatures were unacceptable and noted that residents might not want to eat food at such temperatures. A record review of the Admission Record revealed the facility admitted Resident #40 on 12/09/2016 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Minimum Data Set (MDS) with an Assessment Reference date of 1/3/2025 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of twenty-six (26) sampled residents. Resident #40. Findings Include: Record review of the facility policy Menus revised 10/2022, revealed, .Procedures .2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items . An observation on 1/6/25 at 10:52 AM, revealed a menu hanging in both dining areas that did not include alternate options. An interview on 01/7/25 at 11:13 AM, with Resident #40 indicated that alternate meals are never posted or available for selection. She stated that this situation upsets her because she feels they have no choice but to eat what is provided. Resident #40 explained that, as a diabetic, she may not particularly like the food being served, but she must eat something to avoid getting sick. An interview on 1/8/25 at 7:52 AM, with the Dietary Manager confirmed that the menus were outdated and did not contain alternate options at this time plus their system does not allow them to consider any alternates or individual preferences for the residents. She confirmed that residents should have current menus available, however, they do not provide alternate options for residents because the computerized system formulates their menu for the month based on the resident's allergies, likes and dislikes as identified on admission. She continued by admitting since it included so much information then there was no room for alternative or individual preferences. The Dietary District Manager confirmed that the residents should have the choice of an alternate meal by at least providing an always available menu. A record review of the Admission Record reveals the facility admitted the Resident on 12/9/2016 with diagnoses including Type 2 Diabetes and Hypertension. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/25 revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets for one (1) of four (4) days of survey. Findings Include: Review of the facility ' s policy, Overview of Proper Chemical Use, revised 6/2016, revealed, In order to help prevent accidents from occurring you must follow the following guidelines: 6. If you leave chemicals in the janitor's closet the door must be locked . An observation on 01/06/25 at 10:30 AM, revealed the Janitor Closet on the 200 hall was unlocked and there was a full bottle of 3M Concentrated Glass Cleaner in the closet. An observation on 01/06/25 at 11:19 AM, revealed the Janitor Closet on the Intermediate Care (IC) Hall was unlocked and unattended and there were containers of 3M Concentrated Glass Cleaner and 3M Quat Disinfectant. On 01/07/25 at 3:19 PM, during an interview, Housekeeping Supervisor #2 confirmed that the Janitor Closet's were unlocked. She also confirmed that these rooms were used to store housekeeping carts containing chemicals and cleaning supplies, posing a potential safety hazard, especially for cognitively impaired residents. She disclosed the Janitor Closet doors were keyed. However, she did not possess keys to ensure they remained locked. She revealed that maintenance issues are usually given to maintenance verbally, but she had not notified maintenance of these doors being unlocked but would ask a nurse to notify them. An interview on 01/07/25 at 3:37 PM, with Maintenance Staff #1 revealed that he was unaware of the problems with janitor closets not locking until today. He confirmed that the janitor closets were used to store carts containing chemicals and cleaning supplies, emphasizing the potential safety concern this posed, particularly for residents that are cognitively impaired. An interview on 01/08/25 at 1:45 PM, the Director of Nursing (DON) confirmed that unlocked rooms storing cleaning supplies was a safety issue for residents particularly those that were identified as wanderers and should remain locked. An interview on 01/09/25 at 10:00 AM, the Administrator confirmed not properly securing the janitors closets that housed chemicals posed a potential hazard, especially for cognitively impaired residents. She continued by admitting that any maintenance issue should be clearly communicated and corrected. A record review of the Safety Data Sheet, dated 6/5/24, revealed Glass Cleaner Concentrate had a Hazard identification classification that indicated Serious Eye Damage/Irritation. Review of Handling and storage revealed Precautions for safe handling included Keep out of reach of children . A record review of the Safety Data Sheet, dated 10/9/18, revealed Quat Disinfectant Cleaner Concentrate ' had a Hazard identification classification that indicated Serious Eye Damage/Irritation and Skin Corrosion/Irritation and May cause chemical gastrointestinal burns. Review of Handling and storage revealed Precautions for safe handling included Keep out of reach of children .

Based on observation, interviews, record review, and facility policy reviews, the facility failed to implement care plan interventions related to wound care when a nurse cleaned a resident's pressure ulcer wound without patting it dry for one (1) of 43 resident care plans reviewed (Resident #64) Findings included: Record review of the facility's policy titled Plans of Care, revised 9/25/2017, revealed, The Individualized Person-Centered plan of care may include .Services are provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of Resident #64's comprehensive care plan revealed . Interventions/Task .Cleanse Stage 4 sacrum with wound cleanser and 4 x 4 gauze. Pat dry with 4 x 4 gauze . During an observation on 1/8/2025 at 12:03 PM, Registered Nurse (RN) #2 did not pat the wound dry with gauze on the sacral region as described in Resident #64's care plan. On 1/8/2025 at 2:20 PM, during an interview, RN #2 admitted she did not pat the sacral region dry with gauze as per Resident #64's care plan. On 1/9/2025 at 12:00 PM, during an interview, RN #3 Minimum Data Set (MDS/Care Plan) nurse, stated that care plans are created to inform staff of residents' care needs and should be followed by all staff. She emphasized the importance of adhering to the care plan when providing care. Record review of Resident #64's Admission Record revealed an admitted [DATE] with diagnoses including Pressure Ulcer of Right Heel, Stage 2 and Pressure Ulcer of the Sacral Region, Stage 4.

Based on observations, staff interview and record review, the facility failed to ensure that the dignity and respect of residents are upheld when feeding during mealtimes for one (1) of 26 sample residents reviewed. Resident #3 Findings includes: An observation and interview on 1/06/25 at 1:30 PM, revealed Certified Nursing Assistant #1 (CNA) assisting Resident #3 with lunch. This observation revealed CNA #1 was standing up while feeding the resident. During an interview with CNA #1 stated that she did not know that she was not supposed to stand up when feeding residents. On 01/07/25 at 12:50 PM, Charge Nurse #1 stated during an interview that she was unaware that staff should sit down when feeding residents. She acknowledged that standing while assisting a resident with meals could raise dignity concerns. On 1/7/25, at 1:04 PM, during an interview with the Director of Nursing (DON) emphasized that CNAs should always sit at eye level when assisting residents with meals. She explained that sitting down prevents residents from feeling intimidated by staff who are standing over them and this approach enables eye contact which helps residents feel more comfortable. She noted that this practice is important as it maintains the residents' dignity. A record review of Resident #3's Admission Record revealed the facility admitted the resident on 1/22/24 with diagnoses including Primary Generalized Osteo Arthritis and Cognitive Communication Deficit. A record review of Resident # 3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/25/24 revealed a Brief Interview for Mental Status (BIMS) of 03 indicating the resident was severely cognitively impaired. Section GG revealed substantial maximum assistance with eating.

Based on interviews, record reviews and facility policy reviews, the facility failed to ensure the comprehensive care plan was implemented, as evidenced by failure to provide oral care during Activities of Daily Living (ADLs) for two (2) of six (6) sampled residents. Resident #3 and Resident #6 Findings Include: Review of the facility's policy and procedure titled, Plans of Care, revised 9/25/17, revealed, .Procedure .The Individualized Person-Centered plan of care may include but is not limited to the following .Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements . Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals . Resident #3 Record review of the Care Plan for Resident #3 revealed (Proper name of Resident has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Disease Process, Impaired balance .Interventions/Task .Personal Hygiene/Oral Care: totally dependent on staff for personal hygiene and oral care . During an interview on 4/15/24 with Resident #3 at 12:43 PM, he revealed that the staff assist him with some of his grooming, however, they have never assisted him in cleaning his teeth. On 4/17/24 at 9:05 AM, an interview revealed Resident #3 reiterated that he would like to brush his teeth daily. He stated staff never offers to help me. He adds that just last week, staff told him they would bring him a toothbrush and toothpaste but as of today it has not happened yet. Record review of the Admission Record revealed Resident #3 was admitted to the facility on [DATE]. Current diagnoses include Morbid (Severe) Obesity and Muscle Weakness. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #3 was cognitively intact. Resident #6 Record review of the Care Plan for Resident #6 revealed (Proper Name of Resident #6) has an ADL self-care performance deficit r/t dx (diagnosis) of Cerebrovascular Disease with Hemiplegia/Hemiparesis on right side .Interventions/Task .Oral care: Requires setup or clean-up assistance .Oral care routine . During an interview on 4/15/24 at 2:11 PM, Resident #6 revealed he had not received oral care since arriving at the facility in September 2023. He stated staff members promised him a toothbrush and toothpaste last week, but it has yet to arrive. Record review of the Admission Record revealed Resident #6 was admitted to the facility on [DATE]. Current diagnoses include Lack of Coordination, Stiffness of Joints, and Hemiplegia and Hemiparesis Affecting Right Non-Dominant Side. Record review of the MDS with an ARD of 4/3/24 revealed Resident #6 had a BIMS score of 15 indicating no cognitive impairment. On 4/17/24 at 10:47 AM, in an interview with the Minimum Data Set (MDS), she stated that the aim of the care plan is to create a plan of care for the residents that is tailored to their specific needs. She suggests that everyone should adhere to the care plan, as it serves as a guide for how the residents' needs should be met. She stated if it is not followed, the residents' needs will not be met. During a post survey telephone interview on 4/18/24 at 10:33 AM, with the Administrator, she revealed she expects staff to follow the residents' care plans, as they serve as an individualized guide to the care of the residents.

Based on observation, interviews, record review, and policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of four (4) sampled residents with pressure ulcers. Resident #5 Findings include: Review of the facility's policy titled, Skin and Wound, revised 1/24/2, revealed, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries . Process: Pressure Injury Prevention . 3. Nurse is to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record . Skin Impairment Identification: 1. Document presence of skin impairment(s)/ new skin impairment(s) when observed and weekly until resolved. 2. Nurse to report changes in skin integrity to physician/physician extender, resident/resident representative and document in the medical record . On-going Evaluation 1. Evaluate the effectiveness of interventions, and progress towards goals during the standard of care and the care plan meetings On 4/16/24 at 8:43 AM, an interview the Interim Director of Nursing (IDON) stated they have not had a wound care nurse for two weeks, as the wound care nurse resigned. She revealed a Nurse Practitioner (NP) comes on Wednesday and measures the pressure and vascular wounds. The facility has all her assessments uploaded to the resident's computerized chart by the following Monday, so the staff can have access to them. The IDON stated she expects staff to do wound care and chart the care in the resident's chart. On 04/16/24 at 3:45 PM, an observation of wound care for Resident #5 revealed while performing wound care to the resident's sacral wound, Licensed Practical Nurse (LPN) #1 did not apply the Dakins moist dressing to the wound bed prior to covering the wound with foam border gauze. Record review of the Order Summary Report, with active orders as of 4/17/24 revealed an order dated 2/9/24 Wound Care: Clean unstageable pressure wound to Sacrum, with full strength Dakins, Place Dakins moist gauze to wound bed, cover with foam brooder (boarder) gauze every day shift . On 4/16/24 at 4:28 PM, in an interview regarding the wound care, of Resident #5, Licensed Practical Nurse (LPN) #1 confirmed that she did not apply the Dakins moist gauge to the wound bed prior to covering the wound with the border gauze. The nurse stated the physician's orders for wound care are written to aid in the healing of the wound and should be followed. On 4/16/24 at 4:40 PM, in an interview with the IDON, she confirmed that LPN #1 should have followed physician orders, as the moist dressing aids in healing the wound. The IDON added that by not following the physician's orders, there is a possibility the wound could get worse. Review of the Admission Record, revealed Resident #5 was admitted to the facility on [DATE].Current diagnoses include Alzheimer's Disease, Type 1 Diabetes Mellitus, and Atherosclerotic Heart Disease.

Based on observation, interviews, and record reviews, the facility failed to ensure dependent residents received Activites of Daily Living (ADL) care to include oral hygiene for two (2) or six (6) sampled residents. Residents #3 and #6 Findings Include: Record review of the facility's policy and procedure titled, Activities of Daily Living, dated 2/1/22, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing and assistance as necessary. ADLs include bathing, dressing, grooming, hygiene, toileting and eating. Procedure: 1. CNA (Certified Nurse Aide) will review the resident Kardex (facility software that includes individualized resident care) for information on individual care needs and preferences . Resident #3 In an interview on 4/15/24 at 12:43 PM, Resident #3 revealed that some of his grooming is done by staff, with the exception of assisting him in cleaning his teeth. He added that not having his teeth brushed irritates him but he has not brought it up. In an interview on 4/17/24 at 9:05 AM, Resident #3, once again emphasized his desire to brush his teeth every day. He explained that his toothbrush and toothpaste were in his nightstand drawer to his right, but he could not reach over to retrieve them. He added that he only needs someone to remove the items from his drawer and place them on the overbed table, as he can brush his own teeth, but staff have never offered to help him. Record review of the Admission Record revealed Resident #3 was admitted to the facility on [DATE]. Current diagnoses include Morbid (Severe) Obesity and Muscle Weakness. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #3 was cognitively intact. Resident #6 During an interview on 4/15/24 at 2:11 PM, Resident #6 revealed he had not received oral care since arriving at the facility in September 2023. He stated staff members promised him a toothbrush and toothpaste last week, but it has yet to arrive. On 4/16/24 at 12:53 PM, Resident #6 stated in an interview that the CNAs had never approached him about oral care or offered to provide him a toothbrush or toothpaste to brush his own teeth. He denied ever declining this kind of care. He added that he wants to brush his teeth every day. A record review of the Admission Record for Resident #6 revealed the facility admitted the resident on 9/28/23. Current diagnoses include Lack of Coordination, Stiffness of Joints, and Hemiplegia and Hemiparesis Affecting Right Non-Dominant Side. A record review of the Quarterly MDS, for Resident #6, with ARD of 4/3/24 revealed a BIMS score of 15, indicating the resident was cognitively intact. During an interview with the Interim Director of Nurses (IDON) on 4/16/24 at 11:35 AM, she revealed that residents should have the choice of brushing their teeth daily. The Certified Nursing Assistants (CNAs) should do it or let the residents do it themselves. She points out that it is the role of the CNAs to help provide toothbrushes and other dental hygiene supplies. On 4/17/24, during an interview with CNA #1, she stated that she is occasionally assigned to care for Resident #6. She revealed that this resident has limited mobility and should be assisted with grooming tasks, such as brushing his teeth. She confirmed that the resident should be assisted in cleaning his teeth on a daily basis, as this is part of the grooming process for which CNAs are accountable. During a telephone interview on 4/18/24 at 10:33 AM, with the Administrator, she revealed she expects the CNAs to provide top to bottom care for residents as needed. The CNAs are to follow their task list when doing care. This means taking care of their hair, nails, and teeth, she wants it all done.

Based on record review, interviews, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for two (2) of five (5) residents reviewed. Residents #2 and #5. Findings include: Record review of the facility policy titled, Policies and Procedures, with Subject: Resident Rights, dated 11/30/14, revealed, It is the policy of The Company to .1. Ensure that residents' rights are known to staff .5. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations . Resident #2 Record review of the Facility Investigation dated 9/25/23, and an Incident Report for Resident #2, dated 9/24/23, revealed that Resident #2 had reported to the Director of Nurses (DON) that Certified Nurse Aide (CNA) #3 was very mean and rude. Record review revealed an attached statement from Resident #2, recorded and signed by the Administrator, dated 9/26/23. In the statement, Resident #2 stated that a few days ago, which was determined to be Sunday, 9/24/23, a CNA was rude and mean to her while providing incontinent care and when asked not to be so rough, the resident stated the CNA did not respond verbally to the request, however, the resident revealed the CNA seemed to get rougher. On 10/18/23 at 10:45 AM, an interview with the Administrator revealed she was made aware of the allegation of mistreatment of Resident #2 by the Director of Nurses (DON) on 9/24/23, and a thorough investigation resulted in the end of the employment of CNA #3. The Administrator described Resident #2 as alert, oriented and well spoken. The Administrator stated that a review of the personnel folder for CNA #3 revealed previous concerns regarding treating residents rudely. On 10/19/23 at 4:20 PM, during a telephone interview with the Resident Representative (RR) for Resident #2, she revealed that the resident had been discharged from the facility due to change a in condition and was unavailable for interview because she was in the Intensive Care Unit (ICU) in a hospital in another state. The RR stated that she was the resident's daughter and that her mother had reported to her that CNA #3 was rude and mean to her during care on or around 9/24/23. The RR stated she was sure the resident was making an accurate allegation because she (CNA #3) was rude to me too. On 10/19/23 at 6:20 PM, an interview with the DON confirmed that Resident #2 had reported an allegation of disrespectful treatment which resulted in suspension of CNA #3 during a thorough investigation. The DON confirmed that the employment of CNA #3 was terminated as a direct result of the investigation. She stated that the facility conducted an Education In-Service for all facility staff on 9/26/23 titled Abuse, Neglect and Reporting, Incontinence Care Attitudes with included instructions and policy and regulation review. The DON stated that all residents should be treated with dignity and respect, and it was against facility policy and current standards of care to treat residents otherwise. On 10/20/23 at 4:55 PM, an interview with the Administrator revealed that she stated that the facility had provided in-service training for all staff on 9/26/23 regarding Resident Rights and treating residents with respect and dignity, following an incident with Resident #2. Record review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis, Acute Myocardial Infarction and Congestive Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/23 revealed a Brief Interview for Mental Status Score (BIMS) of 15 indicating Resident #2 was cognitively intact. Resident #5 On 10/18/23 at 12:30 PM, during an interview with Resident #5, the resident reported that last night, the resident was not sure of the time, he had slid out of his bed and that when his CNA (he did not know the CNA's name) had entered his room, she had yelled at him to get up. He reported that when the CNA realized that he was unable to get up without assistance, she summoned the nurse and they had assisted him back into bed and left him lying in bed, like a sack of potatoes. Resident #5 said he had to scoot himself around to get positioned in his bed. Resident #5 revealed that being yelled at and left that way in bed, left him feeling undignified. Resident #5 described his treatment by the CNA as mean and hateful. On 10/18/23 at 12:45 PM, in an interview with the Resident #5's roommate, an unsampled resident, he revealed that last night he woke up and saw Resident #5 on the floor. The resident stated he was unsure of the time, but realized it was still dark outside. Resident #5's roommate said the CNA who came into the room (he did not know her name) was rude and hollered at Resident #5 to get up. Resident #5's roommate stated that he told the CNA He can't get up, you got to help him. Resident #5's roommate commented that after they got Resident #5 back in bed, they just left him and confirmed that he saw Resident #5 moving himself around in the bed, trying to get straight. On 10/19/23 at 5:00 PM, an interview with the Administrator revealed she was not aware that Resident #5 had been found on the floor or that there was an allegation of disrespect or undignified treatment. She stated that the incident should have been reported to her. She stated all incidents involving falls are reviewed by the interdisciplinary team. On 10/19/23 at 6:05 PM, an interview with Registered Nurse (RN) #1 revealed she was the RN Supervisor for the building and usually worked 8:00 AM to 4:30 PM every Monday through Friday. She stated that all incidents, including falls, were supposed to be documented by nurses and are reviewed every morning by the interdisciplinary team during their morning meeting. She stated that there had been no reported fall or allegation of mistreatment regarding Resident #5 recorded by the nursing staff on the night of 10/17/23 or predawn hours of 10/18/23. RN #1 stated that when a resident is found on the floor, it is considered a fall, and an incident report should have been done. RN #1 stated that the roommate of Resident #5 had reported an incident of a fall involving Resident #5 and disrespectful treatment by staff during Resident #5's care, on 10/19/23 at approximately 6:00 PM. On 10/19/23 at 6:17 PM, a telephone interview with Licensed Practical Nurse (LPN) #1 revealed that Resident #5 had been located on the floor of his room next to his bed during the predawn hours of 10/18/23. LPN #1 stated that she had been summoned to Resident #5's room by CNA #4 and observed Resident #5 sitting on the floor next to his bed. She stated that she and the CNA #4 assisted the resident to transfer back into his bed. She stated that she could not remember if she documented any progress notes, filled out an incident report, or completed any documentation of the fall. She stated she did not notify the primary physician or the resident's RR, as the resident had stated that he slid out of bed and denied any injuries. She stated she had reported the fall to the oncoming shift during the shift change report. On 10/19/23 at 6:20 PM, She stated she was not aware that Resident #5 had voiced an allegation of being treated with lack of respect or that he had had a fall during the nighttime hours of 10/17/23 or predawn hours of 10/18/23. She said that Resident #5 had a condition which she observed as progressing recently, leaving him weaker and less able to assist with transfers. She stated that she thought it would have been disrespectful for staff to ask to instruct the resident to do things he was not physically able to do or to leave the resident without repositioning in bed, following a floor to bed transfer. On 10/19/23 at 6:30 PM, during a telephone interview with CNA #4, the CNA confirmed she had observed Resident #5 sitting on the floor next to his bed in his room during the predawn hours of 10/18/23 and summoned LPN #1 to the resident's room for assistance. CNA #4 stated that she kept telling him to use his legs, but he wouldn't, so she scooped his legs up onto the bed. CAN#4 commented that everything they asked him to do he, he wouldn't. CNA #4 confirmed that Resident #5 stated that he couldn't help. She confirmed that Resident #5 was not repositioned after he was assisted back into his bed. CNA #4 stated, I didn't know what was wrong with him, it was never explained to me. CNA #4 did state that care instructions for each resident was available to all CNAs on the kiosk (computer with software for documenting care). On 10/20/23 at 4:55 PM, an interview with the Administrator confirmed that at least three staff members had been aware of the incident which occurred in the predawn hours of 10/18/23, during which Resident #5 was observed on the floor of his room. She confirmed that yelling or hollering at a vulnerable resident on the floor to get up or use his legs and that leaving the resident without repositioning him in bed did not provide the resident with respectful or dignified care. She stated, We are going to just keep working on it. Record review of the Admission Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Unsteadiness on feet, Other lack of coordination and Generalized anxiety disorder. Record review of the MDS with an ARD of 8/24/23 revealed a BIMS score of 14 indicating Resident #5 was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a dependent resident received the necessary services to maintain good grooming and personal hygiene for one (1) of eight (8) residents reviewed for activities of daily living (ADLs). Resident #6. Finding Include: Record review of the facility policy titled Activities of Daily Living, with effective date 2/01/22, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cueing and assistance as necessary. ADLs includes bathing, dressing, grooming, hygiene .Procedure: CNA (Certified Nurse Aide) will review the resident's Kardex for information on individual needs and preferences . On 6/26/23 at 3:30 PM, an observation of Resident #6, revealed he was seated in a wheelchair next to the A/B Nurses Station wearing a green and white three button collared pullover shirt. The collar of his shirt was shredded. It had multiple strings hanging from the collar and the placket. Observation revealed Resident #6 had long, jagged, dirty fingernails which extended past the tips of his fingertips. On 6/27/23 at 10:40 AM, an observation of Resident #6 revealed he was seated in a wheelchair next to the A/B Nurses Station wearing a green and white three button collared pullover shirt. The collar of his shirt was shredded. It had multiple strings hanging from the collar and the placket. Observation revealed Resident #6 continued to have long, jagged, dirty fingernails which extended past the tips of his fingertips. On 6/27/23 at 11:05 AM, an observation and interview with the Director of Nurses (DON) of Resident #6, revealed that she was not aware that Resident #6 was wearing the same shirt that he had been wearing on 6/26/23. She was not sure if it had been laundered, but said she did not think there had been adequate time for a shirt worn the day before to be laundered and returned to the resident. She stated that the shirt looked raggedy, and that the resident should not have been dressed in the shirt if other shirts were available. The DON confirmed that the resident's fingernails were too long, dirty, and jagged. She stated that the Certified Nursing Assistants (CNAs) and nurses assigned to resident care were responsible for nail care and that the CNAs were responsible for dressing residents appropriately. On 6/27/23 at 11:15 AM, an interview with Certified Nurse Aide (CNA) #1 assigned to the care of Resident #6 stated she had gotten resident out of bed on the morning of 6/27/23. The CNA confirmed that he had been wearing the damaged green and white shirt when she got him up. She confirmed that she had not changed his shirt. While discussing ADL care, the CNA made no other comments regarding care provided for Resident #6 on the morning of 6/26/23, only shrugging her shoulders. Record review of the Admission Record' for Resident #6, revealed the resident was admitted by the facility on 7/09/18, with diagnoses that included Cerebral Infarction (Stroke), Parkinson's Disease, Contracture of the Left and Right Hand, and Flaccid Hemiplegia Affecting Left Nondominant Side. Record review of the 5-Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/11/23, for Resident #6 revealed the resident had a Brief Interview for Mental Status (BIMS) score listed as 99 score indicating the resident was unable to complete the interview. Further MDS review revealed Resident #6 was totally dependent on one-person physical assistance for dressing and personal hygiene.

Based on observation, resident and staff interview, and facility procedure review the facility failed to ensure a clean and homelike environment for two (2) of (2) days of survey. Findings include: Record review of the facility provided contracted housekeeping procedure revealed the procedure with Revision Date 10/25/15 stated, SUBJECT-step Daily Washroom Cleaning .To show housekeeping employees the proper method to sanitize a washroom or bathroom in a long-term care facility .7-Steps Daily Washroom Cleaning 3. Dust Mop Floor .always dust mop the floor. 4. Clean and Sanitize Sink and Tub. The sink includes: the sink, fixtures, pipes under the sink .low pipes are always the most difficult areas to get- do not forget them. 6. Spot Clean Walls .Wipe walls-especially by trash containers, light switches, and door handles. Damp Mop Floor Use proper mop and germicide solution to disinfect the floor. Be sure to run mop along edges and never push dirt into corner. The procedure provided titled Daily Room Cleaning with Revision Date of 10/25/15 stated, PURPOSE: To teach Environmental Services employees the proper learning method to sanitize a patient room or any area in a healthcare facility. 5-Step Patient Room Cleaning Procedure .Spot Clean walls .Vertical surfaces are not completely wiped down daily - but must be spot-cleaned. Walls .light switches and door handles - will need special attention .Dust Mop The entire floor must be dust mopped - especially behind dressers .All corners and along all baseboards must be water pushes dust into corners, problems occur .Damp Mop Remember - The procedure is to damp mop- not wet mop (the most important area of a patient's room to disinfect is the floor. This is most air-borne bacteria will settle and so it needs to be sanitized daily. On 6/26/23 at 11:25 AM, observation and an interview with Resident #3, in her room revealed she stated that she was concerned about the condition of the bathroom attached to her room and reported foul smell emanating from the bathroom when the door was open. On 6/26/23 at 11:33 AM, observation and an interview with Resident #4, in her room revealed that she was concerned about the condition of the bathroom attached to her room and reported foul smell emanating from the bathroom when the door was open. She stated, There ' s toothpaste spattered on the door and the walls and it ' s gross. She reported that the bathroom appeared dirty to her, and she stated, there is mold on the wall behind the dresser and those two (2) wardrobes. The Maintenance Man showed it to me. She clarified that the Maintenance Man who showed her the wall was no longer employed at the facility. She stated that she had not reported the condition of the wall to anyone because, he showed it to me, so I knew that they knew about it, there was no reason for me to report it. Observation revealed that the bathroom attached to Resident #4 ' s attached bathroom had a foul, sour, stale odor and appeared dirty. The floor under the sink and behind the toilet and the baseboards around the room had a layer of gray/brown dry substance which wiped away easily with toilet paper and water. The corners of the room and the area beneath the door hinges were black. The floor was stained with green, pale rusty red, and yellow areas of linoleum that did not wipe away. There were seven (7) white spots on the inside door of the bathroom that ranged in size from a grain of rice to the size of a kidney bean which wiped away easily with toilet paper and water. The light switch cover was metal and had a rust-colored substance spread diffusely over the entire cover which wiped away with toilet paper and water. The plumbing fixtures beneath the sink and open to observation were covered with an abrasive rust-colored substance. On 6/26/23 at 12:15 PM, an interview with the Administrator in the bathroom of room [ROOM NUMBER] revealed that upon observations she stated the bathroom needed to be cleaned. She said that the substance on the plumbing under the sink was rusty and said, it needs to be replaced. She confirmed that the substance on the inside of the door looks like toothpaste. She confirmed that the light switch cover needed to be cleaned and that it was considered a high touch surface and appeared to be covered with a light covering of rust. She confirmed that there she smelled a malodorous smell in the bathroom. She stated the baseboards were dusty and needed to be dusted and cleaned. She stated she did not believe the black substance on the floor in the four corners and below the hinges of the door was mold but stated that it needed a ridged scrapping tool to scrape it up. She stated that she would notify the housekeeping staff immediately to clean the bathroom of room [ROOM NUMBER]. She confirmed that the bathroom did not smell or appear clean. On 6/27/23 at 10:30 AM, the State Agency (SA) observed the ice machine located in the facility dining room next to the A/B Nurse ' s Station. The ice machine was clean and had the appearance of being well maintained. The ice machine was full of ice. There was a clean, plastic scoop in a clear plastic holder attached to the wall next to the ice machine. The floor behind the ice machine was wet with standing water. a puddle of water approximately 1218 (twelve by eighteen) inches that was approximately 1/32 (one thirty-second) of an inch deep behind the ice machine in the facility Dining Room. There was a thick coating of a dry, gray substance on the baseboard and water lines (tubing) behind the ice machine that easily wiped from the baseboards and tubing. There was a flat, black substance on the floor and baseboards behind the ice machine. The linoleum floor tiles beneath and around the ice machine were discolored with gray, brown, and black areas that did not wipe from the tiles. On 6/27/23 at 5:30 PM, observation and an interview with the Administrator in room [ROOM NUMBER] revealed an area of flat black substance on the wall approximately eight (8) inches in length (top to bottom) which extended approximately two (2) inches wide on each wall in the corner between the bathroom wall and the wall on the right side of the room when facing the window from the door. The flat black substance was also visible on the wall behind the dresser. The substance was visible between the wardrobe and the dresser. The furniture was too heavy for SA to move to see how far the substance spread on the wall behind the furniture. Residents #3 and #4 had belongings and clothes stored in the wardrobes and the dresser. The Administrator was present in the room and stated that there was not staff at the building at the time capable of moving the furniture. The Administrator confirmed that she could see the black substance on the wall and that she was also unable to see behind the furniture to determine how far the substance spread along the wall. She said that she had not been made aware of the substance on the wall, and that no one had reported it to her. She stated that the furniture needed to be moved, the wall cleaned to remove the substance and the wall needed to be painted after removal/cleaning of the substance from the wall. She stated that she intended to investigate and get the maintenance department to check for any leak possible in the plumbing in the wall between the bathroom and the wall of room [ROOM NUMBER]. She stated that the former Maintenance Supervisor was no longer employed at the facility and that a new Maintenance Supervisor was to report for work at the facility in two weeks. She confirmed that the facility was currently relying on a Maintenance Assistant for maintenance needs at the facility. She stated that based on observation of the bathroom attached to room [ROOM NUMBER] the floor covering needed to be replaced due to the stains which were not removed with cleaning. She confirmed that she also thought the plumbing fixtures that she described as rusty needed to be replaced. She stated that while the floor appeared cleaner, the corners needed more attention and cleaning to remove the remaining black discoloration in the four (4) corners. On 6/27/23 at 1:04 PM, an interview with Resident #5 revealed she had concerns about the physical environment of the facility. She stated that she had observed mold or mildew in areas of the facility, including but not limited to walls and floors in various areas. She stated that she felt the entire facility needs to be cleaned. Resident #5 voiced specific concerns related to the ice machine. On 6/27/23 at 3:55 PM, observation and an interview with the Administrator revealed the Administrator confirmed the presence of a puddle of water approximately 1218 (twelve by eighteen) inches that was approximately 1/32 (one thirty-second) of an inch deep behind the ice machine in the facility Dining Room. The Administrator confirmed there was a thick coating of a dry, gray substance on the baseboard and water lines (tubing) behind the ice machine that easily wiped from the baseboards and tubing, and that there was a flat, black substance on the floor and baseboards behind the ice machine. The Administrator confirmed that the linoleum floor tiles beneath and around the ice machine were discolored with gray, brown, and black areas that did not wipe from the tiles. The Administrator stated that the puddle of water indicated a leak in the plumbing of the ice machine and needed to be repaired. She stated that the linoleum tiles needed to be replaced. She stated that the entire area behind the ice machine needed to be cleaned. The Administrator reported that the facility had removed the old ice machine and replaced it with a brand new ice machine. On 6/27/23 at 4:05 PM an interview with the District Housekeeping Supervisor revealed she confirmed that the bathroom attached to the room of Resident #3 and Resident #4 revealed that she confirmed that the bathroom had rusty light switch cover and rusty exposed plumbing fixtures. She confirmed that the floor of the bathroom had been dirty and the discolorations that remained after her attempt to clean them were stains and that the linoleum needed to be replaced. She confirmed that housekeeping needed to use the scrapper to get the black stuff out of the corners behind the toilet. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/24/23 for Resident #3 revealed she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Record review of the Quarterly MDS with ARD 4/18/23 for Resident #4 revealed she had a BIMS score of 15, which indicated no cognitive impairment. Record review of the Admission MDS with ARD 4/12/23 for Resident #5 revealed the resident had a BIMS score of 14, which indicated no cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a resident whose clinical condition required catheterization received appropriate treatment and services to prevent urinary tract infections for one (1) out of eight (8) residents reviewed. Resident #7. Findings Include: Record review of the facility policy and procedure titled Catheter Care, Urinary, with Revision Date 9/05/17, revealed, .Reattach catheter securement device . On 6/27/23 at 11:50 AM, and again at 12:08 PM, an observation revealed Resident #7 was resting in bed with her catheter tubing coiled and laying on the floor on the right side of the resident's bed. On 6/27/23 at 12:09 PM, an interview with the Administrator revealed the resident's nurse and the Director of Nurses (DON) were not available. The Administrator stated that catheter bags and tubing were not to touch or lie on the floor. On 6/27/23 at 12:11 PM, during an interview with Certified Nurse Aide (CNA) #2, she confirmed that Resident #7's catheter tubing was laying on the floor. She stated that the facility had provided Infection Control In-Services which included care to be taken with catheters, catheter tubing, and catheter bags. She stated that In-Service training included instructions to keep catheter tubing and urine collection bags from touching the floor to prevent infection. On 6/27/23 at 4:10 PM, an observation revealed the Resident #7 was resting in bed with her urine collection bag resting on the floor on the right side of her bed. Resident #7 had her bedspread and sheet pulled back which revealed she did not have a leg strap in place to secure the catheter tubing. On 6/27/23 at 4:15 PM, during an interview with CNA #3, she confirmed that Resident #7's urine collection bag was laying on the floor. The CNA also confirmed that Resident #7 did not have a leg strap to secure her catheter tubing. She stated that the facility had provided Infection Control In-Services which included care to be taken with catheters, catheter tubing and catheter bags. She stated that In-Service training included instructions to keep catheter tubing and bags from touching the floor to prevent infection. On 6/27/23 at 4:30 PM, during an interview and observation of Resident #7 with the DON, she confirmed that Resident #7 did not have leg strap in place to secure the catheter tubing to the leg to prevent pulling of the foley catheter, which could cause irritation. The DON also confirmed that catheter bags and tubing should not lie on the floor, as it could be a source of infection. Record review of the Order Summary Report, dated 6/27/23, for Resident #7 revealed the resident had a physician order, dated 4/24/23, for a foley catheter. Record review of the Admission Record, for Resident #7 revealed the resident was admitted by the facility on 4/24/23, and had diagnoses that included Type 2 Diabetes Mellitus, and Urinary Tract Infection (UTI). Record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/29/23, for Resident #7, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Further MDS review revealed that Resident #7 required assistance with all ADLs (Activities of Daily Living), was not ambulatory and had an indwelling urinary catheter.

Based on interviews, record review, and job description review, the facility's administration failed to use its resources effectively to ensure residents received physician-ordered services for five (5) of 24 residents reviewed, with the likelihood to affected any resident who needed outside transportation. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's Administration's failure to ensure residents received physician-ordered services which caused Resident #31 to have decreased mobility, Resident #75 to be hospitalized , Resident #87 to have a wound infection, and Resident #254 to have sepsis. There was a likelihood of harm for Resident #34 due to a delay in changing a newly placed supra pubic catheter. The failure placed these residents, and other residents who are at risk in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.70 Administration, F835 was lowered from a K to a scope and severity of a E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the job description entitled Executive Director I documented, .The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be always provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Responsible for day-to-day clinical and administrative activities of the facility .Duties and Responsibilities . Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations .Support and guide the facility's quality improvement process .Attend to overall operation of the facility . On 05/04/23 at 03:40 PM, in an interview with the Administrator regarding transportation issues and residents missing outside medical appointments, he revealed that the local ambulance service had stopped all non-emergency transportation in June of 2022, when he first started working at the facility. He also revealed one of the facility's vans broke down in February 2023, due to an automobile accident and the facility's second van kept breaking down and needing repairs. He explained the facility had to move outside appointments around during this time, due to the lack of transportation. The Administrator confirmed that he had notified the Corporate office of the facility's issues with transportation and was told that they were working with the insurance company to purchase a replacement van. He explained that the corporate office had rented a van, but only for a few weeks and there were several times that he had no other option than to use the local ambulance company for non-emergent transportation for dialysis residents and had to pay between $400-800 out of his pocket and wait for the corporate office to reimburse him. The Administrator noted when the physicians wrote orders for appointments, the Director of Nurses (DON) would set up the appointments. However, due to lack of transportation, many times the scheduled appointments had to be canceled and re-scheduled. The Administrator confirmed he informed the Regional [NAME] President of Operations (RVPO) of every issue. However, he could not afford to continue to pay for transportation out of his pocket and the corporate office had not directed him to rent a van. On 05/04/23 at 4:40 PM, in an interview with the Director of Nurses (DON), she confirmed she set up all the physician appointments. She stated that many times the re-scheduled appointments had to be canceled due to lack of transportation. The DON revealed she informed the Administrator of all missed appointments. On 05/08/23 at 5:00 PM, in an interview with the RVPO, she confirmed she was informed when the van was disabled on 2/10/23. She stated she told the Administrator to schedule appointments as needed and use petty cash or pay for the non-emergent transportation with the local ambulance company and fill out expense report. She stated the expense report takes one week to one and half weeks to reimburse. She stated she was not aware of residents missing appointments. She stated the Administrator did not follow company policy. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. * Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. ) The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on interviews, record review, and facility policy review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program to ensure transportation was provided for outside medical services for five (5) of 24 sampled residents, with the likelihood to affect any resident who required outside transportation. The facility's failure to maintain an effective QAPI program placed residents who require outside transportation at risk for serious injury, serious harm, serious impairment, or death. This caused Resident #31 to experience decreased mobility, Resident #75 to be hospitalized , Resident #87 to develop a wound infection, and Resident #254 to become septic. There was a likelihood of harm for Resident #34 due to the delay in changing a newly placed supra pubic catheter. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.75 (a)(1) Quality Assurance and Performance Improvement (QAPI) Program, F865 was lowered from a K to a scope and severity of an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy, Quality Assurance Performance Improvement Program (QAPI) revised 10/24/2022, revealed, Policy: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life .Program Design and Scope 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to: a. Medical b. Clinical care .Important functional areas may include but are not limited to .Quality of care .g. Continuity of care .Review of activities may include but not limited to .d. Interdisciplinary care planning .Leadership: The Central Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to .b) Identify priorities c) Ensures adequate resources .e) Ensures corrective actions are implemented to address identified problems in systems f) Evaluates the effectiveness of actions .4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents and families Identifying Quality Deficiencies and Corrective Actions: The center will monitor department performance systems to identify issues or adverse events .15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s) . Record review of the facility's QAPI sign-in sheet for a meeting held 4/27/23 revealed the Administrator, Medical Director, and the Director of Nursing (DON) were in attendance. During an interview on 5/3/23 at 4:00 PM, the DON confirmed she was aware that the facility had to change residents' physician appointments due to transportation issues and that the facility had to pay in advance for non-emergency transportation with the local ambulance company. She said that it was discussed in the QAPI meeting, and the team decided to rent a van until the facility van was repaired. They also decided to wait until the insurance company finished the negotiations regarding the purchase of a new facility van. During an interview on 05/04/23 at 08:07 AM, with the Medical Director (MD) confirmed he attended QAPI meetings quarterly. The MD said he was told at the last quarterly meeting that the facility had rescheduled some resident appointments because the facility was having problems with transportation, but the facility was addressing the problem and it was resolved. The MD also said he did not know that residents had missed follow up appointments with surgeons. The MD said he remembered stating at the QAPI meeting that residents needed to follow up immediately with their appointments. During an interview on 05/04/23 at 10:32 AM, with the Administrator, he confirmed the Quality Assurance Performance Improvement Program (QAPI) Interdisciplinary Team met quarterly to discuss high risk issues. The Administrator stated the facility met in April in which they discussed the transportation van issues and that the corporate office was working with the insurance company to purchase another van. The Administrator confirmed the interventions put in place were not effective. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1. The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2. The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3. The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4. The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5. The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6. The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7. The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8. The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9. The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM,the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10. The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11. The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments. on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent, requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on observation, interviews, record review, and facility policy review, the facility neglected to provide physician ordered services that were necessary for five (5) of 24 sampled residents. This resulted in actual harm for Residents #31, #75, #87, and #254 and had the likelihood of serious harm for Resident # 34. The facility's failure to provide services necessary to avoid physical harm caused serious harm as Resident #31 experienced decreased range of motion and mobility, Resident #75 was hospitalized for Congestive Heart Failure (CHF), Resident #87 developed a infection of a vascular stent placement, and Resident #254 was hospitalized due to sepsis. There was likelihood of harm for Resident #34 due to a delay in follow-up appointment for a supra pubic catheter placement. This non-compliance put these residents and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders for follow-up appointment. The SA notified the facility Administrator of the IJ and provided an IJ template on 5/5/23 at 12:23 PM. The facility submitted an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 was lowered from a K to a scope and severity of an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy, Abuse, Neglect, Exploitation & Misappropriation policy, revised on 11/16/2022, revealed , Employees of the center are charged with a continuing obligation to treat residents so they are free from .neglect .No employee may at any time commit an act of .neglect .Definitions .Neglect is the failure of the center, its employees or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #31 During an interview on 5/3/23 at 3:30 PM, with the Nurse Practitioner (NP), she revealed Resident #31 had orders to follow up with an orthopedic surgeon in February 2023, but the resident still had not been seen by the surgeon. The NP said Resident #31 could not receive therapy services until he was assessed by the Orthopedic Surgeon and cleared for weight bearing status. She explained that Resident #31 currently had a non-weight bearing status and could not get out the bed until he was seen by surgeon. The NP stated that because he did not go to the post operative appointment, the resident's surgical staples were embedded in his surgical wound, and she had to call the orthopedic surgeon to obtain an order to remove the staples. She also commented that his left foot was turned outward to the left side now and she thought his foot would have to be broken again before anything could be done for him. She said she had talked to the Administrator and the DON several times explaining that Resident #31 needed to go to his post operative appointments. During an observation and interview with Resident #31, on 05/04/23 at 09:42 AM, revealed he was lying in bed wearing a left leg brace that was not secured to his leg, a boot on his left foot with the foot turned outward, and had a right lower extremity amputation. He explained that he was hit by a car prior to entering the facility. Resident #31 said he wanted to get out of his room because he had not left the room since he was admitted on [DATE]. He confirmed that the facility failed to send him to a follow up visit with his orthopedic doctor. He said he was miserable staying in this room all the time watching television and he commented that he had lost one leg and he might lose another leg because it had been so long since he saw the orthopedic doctor. During an interview on 5/04/23 at 10:35 AM, the facility's Physical Therapy Assistant (PTA) confirmed Resident #31 could not participate in therapy services until he was assessed by his orthopedic surgeon to obtain a weight bearing status. The PTA said he had ordered the resident a prosthesis for the newly amputated extremity, but it could not be used because the resident did not have a weight bearing status. The PTA said until the resident was assessed by the orthopedic surgeon, their hands are tied. Record review of the Order Recap Report revealed Resident #31 had a Physician's Order, dated 2/1/23 and discontinued on 3/8/23 for, Follow up appointment: Feb (February) 14, 2023 10:15 A . Post-Op visit . and a Physician's Order, dated 3/8/23 for, Schedule F/U appointment with Orthopedics . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note dated 2/14/23 at 15:44 (3:44 PM) for, .Wound care nurse requests evaluation of multiple areas with sutures, as he had a F/U appointment today with Orthopedics but did not go, will review the reason why with DON. Did document the following appointments on my last visit to be sure he did not miss them. Will again review all appointments with DON . revealed Resident #31 missed follow up appointment. NP will follow up with DON. Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/15/23 at 10:44 AM for, .Reviewed appointments with DON and information for each appointment documented in my note. Yesterday's appointment was rescheduled as the facility's transportation department already had a full calendar prior to his admission . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/28/23 at 12:35 PM, for, NP/F/U stitch removal .Reassessed this resident's multiple surgical areas to see how they are doing after removing sutures last week to his Left leg and the Right AKA (Above Knee Amputation) stump .some sutures remain. On staff attempt to remove sutures some were too embedded to be able to remove. The staff nurse asked me if I could look at them and attempt to remove the remaining sutures. Removed remaining sutures from Right stump and Left thigh area .continues to wear a [NAME] brace to LLE (Left Lower Extremity) and remains NWB (non-weight bearing) LLE and s/p (status post) RLE (Right Lower Extremity) AKA . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 3/8/23 at 11:44 AM, for, .This resident asked if he could start receiving PT (Physical Therapy). I discussed this with the PT department, they are waiting for Weight bearing status update as he is NWB per his discharge paperwork .He had a F/U appointment scheduled for Feb. 14, 2023 that was missed and rescheduled for [DATE] according to the DON but when they called to confirm the 27th appointment prior to transport the DON states she was told they did not have any F/U appointment on the books with Ortho. for this patient at all and no other appointment has been made as of today as I spoke with the scheduling department myself .this AM and she confirmed no F/U Ortho. Appointment for this patient at this time. I discussed this with the DON, she is to schedule that F/U, after that visit we can get weight bearing status and be able to move forward with his PT/OT according to Ortho's recommendations . Record review of the Progress Notes revealed Resident #31 had a Nursing Progress Note dated 3/8/23 at 11:44 AM, for, Called (Proper Name of Orthopedic Facility) .in reference to f/u appt for resident .schedule is filled at the time and he does not have any openings . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 4/25/23 at 13:25 (1:25 PM) for, .He is asking when he remove his left leg brace. I explained to him he has to see Ortho and get the order to remove this brace from them. He voiced concern that he has missed several appointments to go back and see Ortho because of transportation, as he is being told. I spoke with DON and Administrator concerning this resident and his return appointments, they both state they are working on it as it has been a transportation issue. I expressed the importance of getting him back to the Orthopedic ASAP (As soon as possible) for F/U of his surgeries and hospital stay prior to admission on January 31, 2023. They both expressed understanding . Review of the medical record revealed there was no documentation indicating that Resident #31 was seen by the Orthopedic Surgeon as ordered. A record review of the Admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #75 During an interview on 05/01/23 at 03:20 PM, with Resident #75, she stated the facility had failed to schedule and keep follow up appointments for her to see her cardiologist or pulmonologist. The resident said she was concerned because she had been hospitalized for pneumonia and had difficulty breathing. She did not understand why she could not go to her doctor's appointments. During an interview on 5/3/23 at 1:00 PM, with License Practical Nurse (LPN) #2, she confirmed the resident did not go to see her Cardiologist and Pulmonologist because the facility van was inaccessible for the resident and the facility must pay the local Ambulance service in advance for non-emergent transporting of residents. LPN #2 also confirmed the resident was not sent to the hospital for a chest x-ray (CXR). LPN #2 revealed she was given this information by the previous Director of Nursing (DON) and the Administrator. During an interview on 5/3/23 at 4:00 PM, with the current DON, she revealed she was not the DON at the time the Nurse Practitioner (NP) placed the order for the resident to have follow up appointments with the Cardiologist and Pulmonologist. The DON also said she was not the DON when the NP wrote an order for the resident to get a CXR at the hospital. The DON stated she was aware that the local ambulance company required payment in advance for non-emergency transport services and that Resident #75 was not sent to see her Cardiologist and Pulmonologist. The DON also confirmed the resident was not sent to the hospital for a CXR due to transportation problems with the facility. During an interview on 5/3/23 at 3:30 PM, with the NP, she said she wrote an order for the resident to follow up with her Cardiologist and Pulmonologist in January of 2023, and the facility failed to follow her orders. The NP also said she ordered a portable CXR in January 2023 for the resident, but she exceeded 300 pounds, and the technician could not get a good picture. The NP then wrote an order to schedule the resident to have a CXR at the hospital, which was not carried out. The NP stated that she talked to the Administrator and the previous DON about residents not going to ordered appointments. The Administrator told her that the Resident was too large to fit in the company van and that he had to pay the local ambulance in advance before they would transfer any of the residents for non-emergency appointments. The NP reported that she told the Administrator, You admitted the residents now you must take care of their needs. The NP stated that had the facility sent the resident to the follow up visit with the Cardiologist, Pulmonologist, and CXR, the resident would not have had to be hospitalized with Congestive Heart Failure (CHF) and pneumonia. Record review of the Order Summary Report with Active Orders as of 05/03/2023, revealed Resident #75 had a Physician's Order, dated 1/3/23 to Schedule appointment in [NAME], MS with this resident's Cardiologist and Pulmonologist as she is c/o (complaining of) increased heart palpitations and Shortness of breath. She states she has not been seen in over a year. Record review of the Progress Notes for Resident #75 revealed a Physician Progress Note dated 1/24/23 at 18:19 (6:19 PM) for, .The resident reports she is experiencing occasional heart palpitations, states she just feels like her heart is running away from her and she feel short of breath when this happens. Reviewed V/S (vital signs) and noted her BP (blood pressure) is running higher than it should be .Will discuss the status of her order to schedule a F/U (follow up) appointment with her cardiologist and pulmonologist in [NAME], MS that is known to her for a checkup . POC (Plan of Care) .3. CXR c/o SOB (Shortness of Breath). Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note dated 1/26/23 at 18:20 (6:20 PM) for, (Proper Name of Portable X-ray Company) present at this time to do portable CXR, unable to perform r/t (related to) res (resident) weight exceeding 300 pounds per policy .DON notified .NP notified then instructed for CXR to be scheduled and res to be transferred to hosp (hospital) to be obtained . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/1/23 at 10:10 (AM) for, .She states she is having more shortness of breath .her thighs and lower abdomen feel tight .POC .2. Place a Foley (indwelling) catheter today . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/15/23 at 13:38 (1:38 PM), for, Res c/o SOB with difficulty breathing to this nurse .NP present in facility, made aware. N.O. (New Order) to send res to (Proper Name of Local Hospital) . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/15/23 at 18:14 (6:14 PM), for, .admitted .with dx-CHF, pulmonary disease, stable condition noted. Review of the medical record revealed there was no documentation indicating that Resident #75 was seen by the Cardiologist or Pulmonologist, and there was no documentation that she received the diagnostic CXR as ordered. Record review of a hospital History and Physical Note, dated 3/15/2023 at 17:02 (5:02 PM), revealed, .CT (Computed Tomography) of the chest showed evidence of pneumonitis and possible atypical pneumonia. She was admitted . Record review of the Admission Record revealed the facility admitted Resident #75 on 9/12/22 and she had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Diastolic Congestive Heart Failure. Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/23 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated her cognition was moderately impaired. Resident #87 During an interview on 05/03/23 at 03:30 PM, the NP stated that Resident #87 had an artificial implant because of poor circulation that was placed by the vascular surgeon prior to his admission to the facility on [DATE]. The NP said the resident has had complaints of pain and has had recurrent infections with Methicillin-Resistant Staphylococcus (MRSA) in that area because the implant needed to be removed. The NP said she wrote orders last year for the facility to make an appointment to follow up with the vascular surgeon, but the facility kept changing the appointment, and he still has not seen the surgeon. The NP stated that she had asked the DON why the resident had not seen the surgeon and was told it was because the facility's van was being repaired and the dialysis residents have top priority related to transportation. The NP said she told the DON that the resident should not have to continue to be in pain or suffer from infections because the facility had transportation problems. During an interview on 05/03/23 at 04:00 PM, with Resident #87, he confirmed he had pain and recurrent infections in his thigh. The resident said he talked to the NP and explained that his thigh was hurting and that he needed to have the implant removed and the NP said she would have the facility to set up an appointment. The resident was unable to recall the exact month that the NP said she was going to get him appointment, but he knew it was last year. The resident said that his appointments kept getting changed because the facility vans were not working, but he had an appointment scheduled for tomorrow (5/4/23). Record review of the Order Summary Report dated 5/3/23, revealed Resident #87 had a Physician's Order, dated 11/21/22, for refer to (Proper Name of Physician) vascular surgeon at (Proper Name of Medical Clinic), a Physician's Order, dated 3/17/23, for Get appointment with physician at (Proper Name of Medical Clinic) .ASAP (as soon as possible) .related to Unspecified Open Wound, Left Thigh ., and a Physician's Order, dated 4/11/23, for Get appointment with (Proper Name of Physician) vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh . Record review of the Progress Notes for Resident #87, revealed a Physician Progress Note, dated 4/11/23 at 15:00 (3:00 PM) for .The resident states he is having pain to his left groin/thigh. He just completed antibiotic therapy for MRSA to his left groin/thigh wound where he has an artificial implant placed by the vascular surgeon .The implant has given him trouble since insertion, and he was trying to get it removed when he was first admitted here last year. He had infection at that time and keep getting recurrent infection usually MRSA to this same area. Order placed to get him an appointment with (Proper Name of Physician) ASAP now that he has just completed another round of antibiotics on the 31st of March for MRSA. He is c/o pain to this area and leg .Getting him to the surgeon for possible removal of this implant will be what will help him the most to get rid of his pain .POC .Get appointment with .vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh. During an interview on 05/04/23 at 10:48 AM, with the DON, she confirmed the residents' appointments with the vascular surgeon were changed several times because there were problems with both facility vans. The DON explained that one van was out of commision and the other van was in the shop being repaired. The DON said that she tried to rearrange several appointments and that Resident # 87's appointments got lost in the cracks because of all the appointments that had to be canceled. The DON said when she realized the resident's appointment was not made, she called the surgeon's office and asked the nurse to set up an appointment. She confirmed that the resident had complaints of pain and that he had been treated for infections twice since the implant was placed. A record review of the Admission Record revealed the facility admitted Resident #87 on 07/06/2022, and he had diagnoses including Post-Traumatic Stress Disorder (PTSD) and Depression. Record review of the Quarterly MDS with an ARD of 04/05/23 revealed Resident #87 had a BIMS score of 15, which indicated he was cognitively intact. Record review of the Microbiology report for Wound Cultures collected 3/21/23 and reported 3/23/23 for Resident #87 revealed a specimen from the Thigh was collected and resulted in .Moderate Methicillin Resistant Staphylococcus aureus (MRSA) . Record review of the Microbiology report for Wound Cultures collected 4/11/23 and reported 4/15/23 for Resident #87 revealed a specimen was collected from the Thigh and resulted in Light .(MRSA) . Resident #254 On 05/03/23 at 10:10 AM, during an interview with Registered Nurse (RN) #1, she explained Resident #254 was transferred to the hospital from a wound care appointment and has not returned to the facility. RN #1 stated that she scheduled Resident #254 for a wound care appointment on the 4/14/23, but the facility was unable to transport her because of transportation problems. On 05/04/23 at 09:10 AM, during a phone interview with Resident #254's niece, she said she was not aware that Resident #254 had missed the wound care appointment scheduled on 4/14/23, but she was informed that the resident had an appointment scheduled for 04/18/23. On 05/08/23 at 11:10 AM, during a phone interview with the local would care clinic, the staff revealed Resident #254 arrived for the wound appointment. Upon arrival, her vital signs were abnormal, she had a fever, and was lethargic, so the clinic sent her to the emergency room , and she was diagnosed with Sepsis. Record review of the Progress Notes for Resident #254 revealed a Nursing Progress Note dated 4/14/23 at 13:53 (1:53 PM) for unable to take resident to wound care apt (appointment) today will contact family and wound care to reschedule. Resident #34 During an interview on 5/3/23 at 3:30 PM, with the NP, she revealed Resident #34 had a suprapubic catheter placed on 3/24/23 and had orders to return to the Urology for a follow up on 4/19/23. The facility changed the appointment to 5/9/23 because of transportation issues and then changed it again to 5/11/23 due to continued transportation problems. The NP said that she called the Urologists' office on 4/25/23 to ask if she could change the suprapubic catheter since his appointment had been postponed due to transportation problems. The doctor replied, Absolutely not. The doctor then said the resident needed to be in her office by tomorrow because she was concerned about the resident developing an infection. The NP said she took her phone to the Administrator and let him talk to the doctor. She said the Administrator called the facility's transportation staff and rearranged dialysis residents so the resident could be at the Urologists' office the following day. The NP said that if she had not called the doctor herself, the resident would not have had his newly placed suprapubic catheter changed timely. During an interview on 05/14/23 at 08:16 AM, with Resident #34, he confirmed his follow up appointment was scheduled for 4/19/23 and the facility changed the appointment due to transportation issues. Resident #34 said he was told the facility van was in the shop and the facility had to reschedule his appointment to 5/9/23. He explained that later the staff came to him and said they had to change his appointment again to 5/11/23 because they were not sure when the van would be ready. Resident #34 said he was concerned because the doctor told him it was especially important for him to return for his follow up visit in a month. Record review of the Progress Notes revealed Resident #34 had a Physician Progress Note, dated 4/25/23 at 13:56 (1:56 PM), .He is concerned with his newly placed Suprapubic catheter needing changed as it was placed 3/24/23. He was told by (Proper Name of Physician) she would change it for the first time on his return visit for F/U, the appointment was made for 4/19/23, then changed by the facility because of transportation to 5/9/23 and then again because of transportation to 5/11/23. I called the nurse of (Proper Name of Physician) to question whether we, the staff of (Proper Name of Facility) or myself (NP) could change the catheter for the first time since his appointments had been postponed. The nurse states No, the Dr. has to change it for the first time and he cannot wait until 5/11/23 for this to be done, as a matter of fact he needs to be in the office by tomorrow to get it done, as they are worried of an infection developing should he wait that long after surgery to have it changed or even see the Dr. for F/U after surgery. Spoke with Administrator .he contacted the van driver and rearranged some dialysis transports and stated they can have the resident in [NAME] .at 2pm, the nurse put him on the book for 2pm tomorrow . Record review of the Admission Record revealed the facility admitted Resident #34 on 06/22/2020 with a diagnosis of Spina Bifida. Record review of the Significant Change in Status MDS with an ARD of 02/20/23 revealed Resident #34 had a BIMS score of 15 which indicated he was cognitively intact. During an interview on 5/3/23 at 2:00 PM, with the Chief Executive Officer (CEO) of the local ambulance company, he confirmed they required the facility to pay in advance for non-emergency transportation services. During an interview on 05/04/23 at 08:07 AM, with the Medical Director (MD), he stated that he was told at the last Quality Assurance (QA) meeting that the facility had rescheduled some resident appointments because of transportation problems. The MD said he was told the facility had addressed the problem and it was resolved. The MD said he did not know that Resident #37 and Resident #81 had not been able to see their surgeons and recalled stating at that meeting that those residents needed to follow up immediately with their surgeons. The MD also stated that the residents not having transportation to appointments is unacceptable and must be taken care of immediately. The doctor said he thought the transportation problems were resolved. During an interview on 05/04/23 at 09:24 AM, with CNA #1, she said she had been the van transportation driver and took residents to dialysis. CNA #1 confirmed the facility had communication problems with appointments because different nurses and the DON were making appointments. The resident appointments were clashing with each other which caused a lot of confusion and some residents missed appointments because they were scheduled at the same time. During an interview on 05/04/23 at 09:58 AM, with CNA #2, he said he drives the facility's transportation van, but he does not schedule the appointments. CNA #2 stated the facility van was placed in the shop for repairs three (3) times since he started driving the van in February 2023. CNA #2 confirmed the facility rented a van, and dialysis residents were the top priority for transports. CNA #2 said this facility is too big for one van and needs two vans to meet the residents' needs. On 05/04/23 at 11:58 AM, during an interview with the Administrator, revealed one van was disabled in February and the other van kept breaking down and was placed in the shop several times. The Administrator said he emailed his corporate office to let them know that he did not have transportation for the residents to go out to their appointments. He stated that he rented a van to help with dialysis appointments and some local appointments. The corporate office said they were working with the insurance company to try to get another van because the disabled van had not been replaced. The Administrator confirmed that one van could not take all the residents to dialysis and to local and out of town appointments. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain eff [TRUNCATED]

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a functioning call light system was available for residents' bathrooms for 18 residents out of 107 residents that reside in the facility. (Residents #4, #5, #12, #21, #32, #37, #38, #44, #46, #49, #57, #60 #65, #69, #71, #81, #87, and #96) The facility's failure to ensure a functioning call light system was available for residents' bathrooms for 18 residents residing in the facility placed these residents, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/16/23 when a maintenance work order was completed for call light issues but was not acted upon. The facility Administrator was notified of the IJ on 5/2/23 at 5:38 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/2/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/3/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/3/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.90 (g)(2) Resident Call System, F919 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Call Bell System-Inoperable with revision date 08/22/2017, revealed, Policy: Resident must have, at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regular basis by Maintenance. If the Call Bell System is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Procedure: Maintenance, the Executive Director, and the Director of Clinical Services must be notified immediately if any call bell or the system is inoperable . On 05/01/23 at 12:01 PM, during an interview with Resident #49, she reported the bathroom call light does not work in her current room, nor did it work in her previous bathroom when she was in room [ROOM NUMBER]. The resident explained when she tried to pull the call light cords in the bathrooms, nothing happened. Resident #49 revealed that she had reported the non-working call lights to a staff member but does not remember the name. On 05/02/23 at 08:05 AM, observed the metal frame and switch button of the bathroom call light located in the bathroom between 204 and 206 to be covered with a heavy corrosive material. It was very difficult to pull the cord but when the cord was pulled, the light did not work, and the call light switch could not be turned back to off position by pushing the button down. On 05/02/23 at 09:00 AM, during an interview with Resident #46, she reported she has never attempted to use the call light in her bathroom but had been told by staff members that the call light did not work. When the call light was tested , the light did not work. On 05/02/23 at 09:15 AM, during an interview with Resident #37, she reported thankfully she has never had to use her bathroom call light, because it does not work. On 05/02/23 at 09:25 AM, during an interview with Resident #5, she revealed she had never tried to use her bathroom call light, because a night shift employee had told her the light did not work. On 05/02/23 at 09:35 AM, during an observation of the call light button and metal base in the bathroom located between rooms [ROOM NUMBERS], revealed a heavy corrosive substance. When the call light was pulled, the call light did not work. On 05/02/23 at 10:13 AM, during an observation of the call lights in the bathrooms located between rooms [ROOM NUMBERS], 204 and 206, 209 and 211, 400 and 402, 401 and 403, 408 and 409, 414 and 415, and 516 and 518 revealed the call light strings were short and a heavy corrosive substance was noted on the metal base. On 05/02/23 at 10:20 AM, during an interview with Maintenance Director, he explained he has been at the facility for a month and a half. He revealed no one had reported anything to him about bathroom call lights. He explained he is not aware of a maintenance logbook, or a computer system for maintenance requests and that the requests that he had received for needed repairs, had been verbal requests. On 05/02/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she was not aware of bathroom call lights were not working. The DON revealed the nurses and Certified Nurse Aides (CNAs) are responsible for making sure the call lights are within a resident's reach and functioning properly, as it is important for residents to get assistance as quickly as possible to ensure that their needs are met. On 05/02/23 at 10:35 AM, during an interview with Certified Nurse Aide (CNA) #11, she revealed that none of her residents had reported their bathroom call lights not working. In an observation with CNA #11, it was confirmed that the call lights did not work in the bathrooms in room [ROOM NUMBER], 101, and in the joining bathroom for rooms [ROOM NUMBERS]. On 05/02/23 at 10:42 AM, during an interview with the Administrator, he reported he was not aware of bathroom call lights not working. He revealed he expects maintenance to check all call lights weekly, during weekly rounds and make repairs as needed or reported. The Administrator revealed the facility does have a work order system for maintenance. He confirmed that each nurse's station has a work order book for staff to record needed repairs and that maintenance should check the book daily and perform the requested repairs. On 05/02/23 at 10:45 AM, during an interview with CNA #12, she confirmed the bathroom call light for rooms [ROOM NUMBERS] had not worked for a long time and remembered notifying the nurses. On 05/02/23 at 10:46 AM, during an interview with CNA #5 for 400 hall, she explained the call lights in the bathrooms haven't worked for several months and the problem was reported to the last Maintenance Director. Record review on 11:10 AM on 05/02/23, revealed a Maintenance Book was noted at the nurse's station with a record for work order dated 04/16/2023, completed by LPN #13 on night shift. A record review of the Maintenance Work Order with date 04/16/2023 revealed, . rooms listed 203, 206, 209 call lights not showing up on call system or outside door . The work order was blank on the completed part of the form. On 05/02/23 at 11:45 AM , during an interview with Licensed Practical Nurse (LPN) #6, she explained she mostly works the 200 hall and reported some of the call lights have not worked for a long period of time. She revealed she reported the problem to the Administrator and Maintenance Director and has even put the information in the maintenance log. She confirmed she had written a maintenance work order in the maintenance book dated 04/16/2023. On 05/02/23 at 12:20 PM, during an interview with Resident #49, she explained when she was in room [ROOM NUMBER] and tried to use the bathroom call light, it didn't work. She reported her roommate used the call light in the room to call for help. She told the nurse and the CNA that the bathroom call light did not work. A record review of Resident #49's Admission Record revealed the facility admitted resident on 12/13/2022 with the diagnoses of Acute Myocardial Infarction, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified. A record review of Resident # 49's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact, and Section H revealed Resident #49 was occasionally incontinent of bowel and bladder. A record review of Resident #4's Admission Record revealed the facility admitted resident on 02/24/2023 with the diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy and Muscle Weakness (Generalized). A record review of Resident #4's Admission MDS with an ARD of 03/03/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #4 was occasionally incontinent of urine. A record review of Resident #5's Admission Record revealed the facility admitted the resident on 05/05/2014 with the diagnoses of Poly osteoarthritis and Intervertebral Disc Disorders with Radiculopathy, Lumbar Region. A record review of Resident #5's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #5 was occasionally incontinent of urine and always continent of bowel. A record review of Resident 12's Admission Record revealed the facility admitted the resident on 04/09/2018 with the diagnoses of Heart Failure, Unspecified and Flaccid Hemiplegia affecting Right Dominant Side. A record review of Resident #12's Quarterly MDS with an ARD of 02/16/2023 revealed a BIMS score of 14, which indicated cognitively intact, and Resident #12 was occasionally incontinent of urine and always continent of bowel. A record review of Resident #21's Admission Record revealed the facility admitted the resident on 10/19/2018 with the diagnoses of [NAME] Fascial Fibromatosis (Dupuytren) and Muscle Weakness. A record review of Resident #21's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 12, which indicated cognitively intact, and Resident #21 was always continent of bowel and bladder. A record review of Resident #32's Admission Record revealed the facility admitted the resident on 02/22/2022 with the diagnoses of Type 2 Diabetes Mellitus Without Complications and Primary Osteoarthritis, Unspecified Site. A record review of Resident #32's Quarterly MDS with an ARD of 02/16/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #32 was always continent of bowel and bladder. A record review of Resident #37's Admission Record revealed the facility admitted the resident on 05/06/2022 with the diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbances and Psychotic Disturbance. A record review of Resident #37's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #37 was always continent of bowel and bladder. A record review of Resident #38's Admission Record revealed the facility admitted resident on 09/09/2016 with the diagnoses Major Depressive Disorder, Recurrent, Unspecified and Anemia, Unspecified. A record review of Resident #38's Annual MDS with an ARD of 03/08/2023 revealed a BIMS score of 09, which indicated moderately cognitively impaired, and Resident #38 was occasionally incontinent of urine and bowel. A record review of Resident #44's Admission Record revealed the facility admitted Resident #44 on 07/29/2019 with the diagnoses of Arthropathy and Chronic Pain Syndrome. A record review of Resident #44's Quarterly MDS with an ARD of 04/10/2023 revealed a BIMS score of 06, which indicated server cognitively impaired, and Resident #44 was always continent of bowel and bladder. A record review of Resident #46's Admission Record revealed the facility admitted the resident on 02/02/2023 with the diagnoses of Unspecified Dementia, Moderate, With Mood Disturbance and Muscles Weakness (Generalized). A record review of Resident #46's Annual MDS with an ARD of 02/14/2023 revealed a BIMS score of 13, which indicated cognitively intact, and Resident #46 was frequently incontinent of urine and bowel. A record review of Resident #57's Admission Record revealed the facility admitted Resident #57 on 021/15/2020 with the diagnoses of Difficulty in Walking, Not Elsewhere Classified and Dementia. A record review of Resident #57's Quarterly MDS with an ARD of 11/16/2022 revealed a BIMS score of 03, which indicated severely cognitively impaired, and Resident #57 was frequently incontinent of urine and bowel. A record review of Resident #60's Admission Record revealed the facility admitted resident on 09/15/2021 with the diagnoses of Contracture of Right Wrist and Anemia, Unspecified. A record review of Resident #60's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 09, which indicated moderately cognitively impaired, and Resident #60 was always continent of bowel and bladder. A record review of Resident #65's Admission Record revealed the facility admitted the resident on 06/29/2023 with the diagnoses of Stiffness of Unspecified Joint, Not Elsewhere Classified and Contracture of Right Elbow. A record review of Resident #65's Quarterly MDS with an ARD of 04/01/2023 revealed a BIMS score of 07, which indicated moderately cognitively impaired, and Resident #65 is occasionally incontinent of urine and frequently incontinent of bowel. A record review of Resident #69's Admission Record revealed the facility admitted the resident on 08/24/2022 with the diagnoses of COVID-19 and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. A record review of Resident #69's Quarterly MDS with an ARD of 02/20/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #69 was occasionally incontinent of urine and always continent of bowel. A record review of Resident #71's Admission Record revealed the facility admitted the resident on 04/30/2021 with the diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Muscle Weakness. A record review of Resident #71's Annual MDS with an ARD of 04/17/2023 revealed a BIMS score of 14, which indicated cognitively intact, and Resident #71 was always continent of bowel and bladder. A record review of Resident #81's Admission Record revealed the facility admitted the resident on 01/28/2022 with the diagnoses Myalgia, Unspecified Site and Essential (Primary) Hypertension. A record review of Resident #81's Quarterly MDS with an ARD of 04/11/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #81 was occasionally always continent of bowel and bladder. A record review of Resident #87's Admission Record revealed the facility admitted resident on 07/06/2022 with the diagnoses of Post-Traumatic Stress Disorder, Chronic and Major Depressive Disorder, Recurrent, Moderate. A record review of Resident #87's Quarterly MDS with an ARD of 04/05/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident # 87 was always continent of bowel and bladder. A record review of Resident #96's Admission Record revealed the facility admitted the resident on 02/03/2023 with the diagnoses of Leukemia, Unspecified Not Having Achieved Remission and Muscle Weakness (Generalized). A record review of Resident #96's Admission MDS with an ARD of 02/13/2023 revealed a BIMS score of 13, which indicated cognitively intact, and Resident #96 was incontinent of bowel and bladder. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/02/2023 at 5:45 PM On 05/02/2023 at 6:00pm, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure a functioning call light system was available for resident bathrooms. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA determined the facility hired a new Maintenance Director who was not aware of the maintenance repair request forms located at the nurses' stations and will be educated. Attendees were the Executive Director (ED), Director of Nursing (DON), Maintenance Director, Infection Control Preventionist (ICP), Business Office Manager (BOM), Regional Plant Operations (RPO), Regional Director of Clinical Services (RDCS), Regional [NAME] President of Operations (RVPO), and Human Resources Director (HRD). The Medical Director (MD) attended by phone. A review of policy and procedures were: Call Bell System-Inoperable and Communication Failure Nurse Call System which required no changes. On 05/02/2023 at 6:05pm, RVPO educated the Maintenance Director on the location of the maintenance repair request forms located at each nurse's stations for staff to use when notifying maintenance department of any issue related to ensure a functioning call light system. On 05/02/2023 at 6:10pm, RDCS initiated education on Call Bell System-Inoperable and Communication Failure Nurse Call System to ensure a functioning call light system. No current staff or new hire will work without the aforementioned education. On 05/02/2023 at 6:15pm, the emergency call light system for resident bathrooms was audited by observation for 107 residents on census to ensure proper functioning of call system by the Regional Plant Operations (RPO), RVPO, and ED. There were 16 resident bathrooms affecting 26 residents in the facility. Resident bathrooms #101, #103, #109, #203, #204, #206, #209, #409, #414, and #415 were repaired on 5/2/23 by the RPO. Resident bathrooms #211, #308, #310, #400, #402, and #403 had a bell installed by the RPO and ED on 5/2/23 related to the annunciator board light functioning but not sounding at the nurses' station. The residents residing in #211, #308, #310, #400, #402, and #403 were shown a demonstration by the RDCS on 05/02/2023 on how to use the bell in the bathroom. On 05/02/2023 at 7:00pm, an outside contracted vendor was called and scheduled to come to inspect our nurse call light system to ensure additional verification of proper functioning, on May 3, 2023. The facility alleges all corrective actions were completed to remove the immediacy on May 2, 2023, and the Immediate Jeopardy was removed May 3, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1. The State Agency (SA) validated through record review on 05/02/2023 at 6:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure a functioning call light system was available for resident bathrooms. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA determined the facility hired a new Maintenance Director who was not aware of the maintenance repair request forms located at the nurses' stations and will be educated. Attendees were the Executive Director (ED), Director of Nursing (DON), Maintenance Director, Infection Control Preventionist (ICP), Business Office Manager (BOM), Regional Plant Operations (RPO), Regional Director of Clinical Services (RDCS), Regional [NAME] President of Operations (RVPO), and Human Resources Director (HRD). The Medical Director (MD) attended by phone. A review of policy and procedures were: Call Bell System-Inoperable and Communication Failure Nurse Call System which required no changes. 2. On 05/8/2023 at 11:35 AM, in an interview with Maintenance Director stated that stated he attended the in-service on 5/2/2023 in reference to call lights function. in service on call lights. He stated he will keep a daily log of checking call lights daily. He stated they have a quote on getting a whole new system. 3. A record review on 05/09/2023 at 12:00 PM, of the Education in-service record for Maintenance Director. 4. On 05/09/2023 at 12:10 PM, an interview with RVPO stated all parties attended the QAPI meeting. She stated the medical director attended the meeting by phone and came into the facility and signed the sign in sheet. 5. At 12:30 PM on 05/09/2023, during an interview with the Administrator, she confirmed she was in-serviced on call light system and the procedure if the call light system is inoperable. 6. A record review on 05/09/23, of the bathroom call light audit revealed it was done on 05/02/2023. 7. A record review of the Senior Maintenance Director outside contractors came in the building in related to call lights. 8. A recorded review of the call light audit schedule revealed no concerns. All rooms were checked. 9. A record review of the staff in-service on call lights were signed by all staff. 10. On 50/09/2023 at 1:00 PM, SA validated with all staff about call light in-service on call lights and use of alternative bells. The staff validated the steps to take if call lights are not working.

Based on observation, interview, record review, and facility policy review, the facility failed to provide medical services to prevent an avoidable reduction in range-of-motion (ROM) and loss of mobility for one (1) of 24 sampled residents reviewed for ROM. Resident #31. The facility's failure to provide services to prevent the avoidable loss of ROM for Resident #31 resulted in serious injury, serious harm, and serious impairment and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) that began on 2/14/23 when Resident #31 missed the first post operative appointment with an orthopedic surgeon. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (c)(1) Mobility, F688 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A record review of facility policy Contractures Prevention with a revision date of 8/22/2017, revealed Policy: To prevent contracture of extremities for those residents who no longer have full use of their extremities .Each resident must be evaluated for need of contracture prevention procedures . as needed . residents may have braces or splints to prevent or help release contractures . be sure to follow the physician's order . On 05/01/23 at 03:21 PM, in an interview, Resident #31 stated staff will not get him up out of the bed. He stated he has missed two physician appointments due to the facility's van not working. On 5/3/23 at 3:30 PM, in an interview with the Nurse Practitioner (NP) revealed Resident #31 had orders to follow up (F/U) with the Orthopedic surgeon in February. The NP explained the order was for follow-up before the resident could be seen by therapy. The resident was ordered non-weight bearing and could not get out of the bed until the Orthopedic surgeon follow-up appointment. The NP said the resident still had not seen the orthopedic surgeon as of today. The NP said the resident's left foot has turned to the side now. The NP said she has talked to the Administrator and the Director of Nurses (DON) several times explaining the resident's need for a follow up appointment. On 05/04/23 at 09:42 AM, an observation revealed Resident #31 had a right below the knee amputation (BKA). The resident's left leg was noted to be in a brace that was not secured to his leg and the resident's left foot was turned outward. Interview on 05/04/23 at 09:45 AM, revealed Resident #31 stated he wanted to get out of his room. The resident said he has not left his room since he was admitted on [DATE]. The resident said he wanted to go outside and enjoy the fresh air, and it is miserable staying in this room all the time watching television. The resident said he cannot go to therapy until he sees the surgeon. The resident also said he has lost one leg and he feel like he might lose another leg because it has been so long since he had a follow-up with the surgeon. Record review of the Order Recap Report revealed Resident #31 had a Physician's Order, dated 2/1/23 and discontinued on 3/8/23 for, Follow up appointment: Feb (February) 14, 2023 10:15 A . Post-Op visit . and a Physician's Order, dated 3/8/23 for, Schedule F/U appointment with Orthopedics (ortho) . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note dated 2/14/23 at 15:44 (3:44 PM) for, .Wound care nurse requests evaluation of multiple areas with sutures, as he had a F/U appointment today with Orthopedics but did not go, will review the reason why with DON. Did document the following appointments on my last visit to be sure he did not miss them. Will again review all appointments with DON . revealed Resident #31 missed follow up appointment. NP will follow up with DON. Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/15/23 at 10:44 AM for, .Reviewed appointments with DON and information for each appointment documented in my note. Yesterday's appointment was rescheduled as the facility's transportation department already had a full calendar prior to his admission . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/28/23 at 12:35 PM, for, NP/F/U stitch removal .Reassessed this resident's multiple surgical areas to see how they are doing after removing sutures last week to his Left leg and the Right AKA (Above Knee Amputation) stump .some sutures remain. On staff attempt to remove sutures some were too embedded to be able to remove. The staff nurse asked me if I could look at them and attempt to remove the remaining sutures. Removed remaining sutures from Right stump and Left thigh area .continues to wear a [NAME] brace to LLE (Left Lower Extremity) and remains NWB (non-weight bearing) LLE and s/p (status post) RLE (Right Lower Extremity) AKA . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 3/8/23 at 11:44 AM, for, .This resident asked if he could start receiving PT (Physical Therapy). I discussed this with the PT department, they are waiting for Weight bearing status update as he is NWB per his discharge paperwork .He had a F/U appointment scheduled for Feb. 14, 2023 that was missed and rescheduled for [DATE] according to the DON but when they called to confirm the 27th appointment prior to transport the DON states she was told they did not have any F/U appointment on the books with Ortho. (orthopedic) for this patient at all and no other appointment has been made as of today as I spoke with the scheduling department myself .this AM and she confirmed no F/U Ortho. appointment for this patient at this time. I discussed this with the DON, she is to schedule that F/U, after that visit we can get weight bearing status and be able to move forward with his PT/OT (Occupational Therapy) according to Ortho's recommendations . Record review of the Progress Notes revealed Resident #31 had a Nursing Progress Note dated 3/8/23 at 11:44 AM, for, Called (Proper Name of Orthopedic Facility) .in reference to f/u appt for resident .schedule is filled at the time and he does not have any openings . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 4/25/23 at 13:25 (1:25 PM) for, .He is asking when he remove his left leg brace. I explained to him he has to see Ortho and get the order to remove this brace from them. He voiced concern that he has missed several appointments to go back and see Ortho because of transportation, as he is being told. I spoke with DON and Administrator concerning this resident and his return appointments, they both state they are working on it as it has been a transportation issue. I expressed the importance of getting him back to the Orthopedic ASAP (As soon as possible) for F/U of his surgeries and hospital stay prior to admission on January 31, 2023. They both expressed understanding . Review of the medical record revealed there was no documentation indicating that Resident #31 was seen by the Orthopedic Surgeon as ordered. A record review of the Admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. Interview on 05/04/23 at 10:35 AM, with Physical Therapist Assistant (PTA) said the resident could not be seen by therapy until he was seen by his orthopedic surgeon. The therapist said they will need an order for the resident weight bearing status. On 05/05/23 at 9:50 AM, in an interview with Licensed Practical Nurse (LPN) #3 stated she was aware of the van breaking down several times in February and March and Resident #31 missing physician appointments. She stated he cannot get out of bed until he sees his orthopedic doctor. On 05/08/23 at 11:53 AM, in an interview with the current Director of Nursing (DON) revealed Resident #31 cannot put weight on his leg until after he sees the Orthopedic physician for a follow up appointment. She stated he has been in bed since admission on 01/31/23. She confirmed the resident had missed appointments and stated the appointments he missed have been rescheduled. The DON stated the resident must go to his orthopedic appointment by non-emergency ambulance. She stated she informed the Administrator of the importance of the resident keeping his follow up appointment. A record review of Resident #31's admission Minimum Data Set (MDS)with an Assessment Reference Date of 2/7/23 revealed a Brief Interview of Mental Status score of 15, which indicates Resident #31 is cognitively intact. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given.Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on interviews and record review, the facility failed to ensure two (2) of 24 sampled residents received outside medical services as ordered to prevent complications and maintain the highest practicable physical, mental, and/or psychosocial wellbeing. Residents #75 and #87. The facility's failure to provide required outside medical services led to the hospitalization of Resident #75 due to Congested Heart Failure (CHF) and Pneumonia and was admitted to the Intensive Care Unit (ICU) and wound infection for Resident #87 caused serious injury, serious harm, and serious impairment to Resident #75 and Resident #87 and placed other residents in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 missed scheduled appointments with the vascular surgeon and developed two separate infections awaiting rescheduled appointments. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 Quality of Care, F684 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #75 On 05/01/23 at 03:20 PM, during an interview with Resident #75 she complained the facility has not made a follow-up appointment for the Cardiology and Pulmonary doctors and she ended up being in the hospital. Resident #75 voiced she was concerned over missing the doctor appointments because she had to be sent the hospital because she had difficulty breathing and was diagnosed with Pneumonia. She did not understand why she could not go to her doctors' appointments. On 5/3/23 at 01:00 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported Resident #75 did not go to see her Cardiologist and Pulmonologist because the facility van was not accessible to Resident #75 and the facility must pay in advance for non-medical transfers. LPN #2 stated for the same reason, Resident #75 was not sent to the hospital for a chest (CXR) x-ray. LPN #2 reported this information was provided to her by the previous Director of Nursing (DON) and the Administrator. On 5/3/23 at 3:30 PM, during an interview with the Nurse Practitioner (NP), the NP explained she wrote an order for Resident #75 to follow up with her Cardiologist and Pulmonologist in January 2023, which was not done. She had ordered a portable chest x-ray in January for the resident which was not done because her weight exceeded 300 pounds, so she ordered to schedule a chest x-ray at the hospital. The chest x-ray still was not completed. She explained she talked to the Administrator and previous DON about Resident #75 not getting scheduled for appointments. The Administrator told her Resident #75 was unable to fit in the company van and he would have to pay in advance to have residents transported for non-emergencies. The NP reported if the facility would have sent Resident #75 to the follow-up appointments with the Cardiologist and Pulmonologist and scheduled the chest x-ray that Resident #75 would not have been admitted to the hospital with diagnoses of Congested Heart Failure (CHF) and Pneumonia and admitted to the Intensive Care Unit (ICU). On 5/3/23 at 04:00 PM, during an interview with the current DON, she stated she was not the DON at the time the NP placed the order for Resident #75 to follow-up with Cardiologist and Pulmonologist or to get a chest x-ray at the hospital. She stated has been aware of the issue with transportation for residents and appointments because the facility must pay in advance for non-emergency visits. She confirmed that Resident #75 was not sent to her Cardiologist and Pulmonologist and was not sent to the hospital for a chest x-ray due to transportation problems with the facility. A record review of Resident #75's Order Summary Report with active orders as of 05/03/2023, revealed an order dated 01/03/2023, Schedule an appointment in (Proper name of city) with this resident's Cardiologist and Pulmonologist as she is c/o (complains) of Increased heart palpitations and Shortness of breath. She states she has not been seen in over a year. Review of Resident #75's Progress Notes *NEW* revealed a NP progress note dated 01/24/2023 revealed . The resident reports she is experiencing occasional heart palpations, states she just feels like her heart is running away from her and she feel short of breath when this happens . Will discuss the status of her orders to schedule a F/U (follow-up) appointment with her cardiologist and pulmonologist . POC (Plan of Care) 3. CXR (chest x-ray) c/o (complain) SOB (shortness of breath). Review of Resident #75's Progress Notes *NEW* nursing progress notes dated 1/26/23 by LPN #2 revealed . portable CXR, unable to perform r/t (related to) res (resident) weight exceeding 300 lbs (pounds) per policy. Resident aware, DON notified, NP notified then instructed for CXR to be scheduled and resident to be transferred to hospital to be obtained . A record review of Resident #75's Progress Notes *NEW* NP progress notes dated 03/01/2023 revealed . This resident request a couple of days of extra Lasix for increased fluid. She states she is having more shortness of breath even with her 02 (oxygen) NC (nasal cannula) . POC: . 1. Increase PM (evening) dose of Lasix to 80 milligrams (mgs) po (by mouth) Q (every) evening x 5 days . Review of Resident #75's Progress Notes *NEW* nursing progress notes dated 03/15/2023 at 01:38 PM revealed . Resident complained SOB with difficulty breathing . NP present in facility, made aware. N.O. (new order) to send resident to Proper Name for further evaluation . Review of #75's Progress Notes *NEW* nursing progress notes written by LPN #2, dated 03/15/2023 at 06:14 PM revealed . Placed call to Proper Name for follow up, spoke with charge nurse. admitted . with diagnoses Congested Heart Failure (CHF), pulmonary disease . A record review of the History and Physical Note from the local hospital, dated 3/15/23, for Resident #75, revealed, CT (Computed Tomography) of the chest showed evidence of pneumonitis and possible atypical pneumonia. She was admitted . A record review of Resident #75's Admission Record revealed the facility admitted Resident #75 on 09/12/2022, per the Admission Record with the diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Respiratory Failure. A record review of Resident #75's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/23 revealed Resident #79 had a Brief Interview of Mental Status (BIMS) score of 11 that indicated Resident #75 has moderate cognitive impairment. Resident #87 On 05/03/23 at 03:30 PM, during an interview with the NP, she explained Resident #87 has an artificial implant that was place by the vascular surgeon prior to admission for poor circulation and Resident #87 has been constantly complaining of pain and has had recurrent infections in that area because the implant needs to be removed. She wrote orders last year for the facility to make an appointment to follow up with the vascular surgeon, but the facility kept changing Resident #87's appointments. Resident #87 has not seen the vascular surgeon as of today. She asked the DON why Resident #87 has not seen the surgeon and was told because the facility is down a van and dialysis residents have top priority. Record review of the Microbiology report for Wound Cultures collected 3/21/23 and reported 3/23/23 for Resident #87 revealed a specimen from the Thigh was collected and resulted in .Moderate Methicillin Resistant Staphylococcus aureus (MRSA) . Record review of the Microbiology report for Wound Cultures collected 4/11/23 and reported 4/15/23 for Resident #87 revealed a specimen was collected from the Thigh and resulted in Light .(MRSA) . On 05/03/23 at 04:00 PM, during an interview with Resident #87, he confirmed he has been having recurrent infections in his thigh and needed to have the implant removed. Resident #87 reported the NP said she would have the facility to set up appointment, but don't remember what month it was. He did remember it was last year. His appointments kept getting changed because the facility vans were not working. He stated he had an appointment scheduled for 05/04/2023 but he was afraid the appointment may be missed because the facility still only has one van. A record review of Resident #87's Order Summary Report dated 05/03/2023 revealed an order to refer to Vascular surgeon on 11/21/2022, 03/17/23 and 04/11/23. A record review of Resident #87's Progress Notes *NEW* dated 4/11/23 at 05:00 PM Physician Progress note revealed . This resident states he is having pain in his left groin/thigh. He just completed antibiotic therapy for MRSA to his left groin/thigh wound where he has an artificial implant placed by the vascular surgeon . for his PVD (Peripheral Vascular Disease) in the past. This implant has given him trouble since insertion, and he was trying to get it removed when he was first admitted to the facility last year . POC: . Get appointment with Vascular surgeon at (Proper Name) as soon as possible to have artificial implant removed from left groin/thigh . On 05/04/23 at 08:07 AM, during an interview with the Medical Director (MD) he explained he attended the Quality Assurance Performance Improvement/Quality Assurance (QAPI/QA) meeting quarterly and he was told at the last quarterly meeting that the facility had rescheduled some resident appointments because the facility was having problems with transportation, but the facility had addressed the problem and it was resolved. He did not know Resident #87 had not seen the surgeon and remembered telling staff in the meeting that residents need to follow up immediately with their surgeons. He stated that he told staff the transportation issue needed to be taken care of immediately. He thought the transportation problems were resolved. On 05/04/23 at 09:24 AM, during an interview with Certified Nurse Aide (CNA)#1, she explained she was the transportation driver. The facility had communication problems with appointments because the different nurses, residents, and DON were making appointments and the appointments were clashing with each other which caused confusion. Residents missed appointments because several appointments were scheduled at the same time. On 05/04/23 at 10:48 AM, during an interview with the current DON, she confirmed Resident #87's appointments with the vascular surgeon have been changed several times because the facility had problems with both vans. One van was damaged in an accident and the other van was in the shop being repaired. She said she had to try to rearrange several appointments but Resident #87's appointment got lost in the cracks. She stated that when she realized Resident #87's appointment was missed, she called the surgeon's office and asked the nurse to set up an appointment, however, this was several months later. The DON confirmed Resident #87 has had infections twice since he had the implant placed. On 05/04/23 at 11:58 AM, during an interview with the Administrator, he confirmed the facility failed to send Resident #87 out to follow up with his vascular surgeon. One van was disabled in February 2023 and the other van kept breaking down and was placed in the shop several times. He e-mailed his corporate office letting them know he did not have transportation for the residents to go out to their appointments. He rented a van to help with the dialysis appointments and some local appointments. He stated that the corporate office said they were working with the insurance company trying to get another van and the disabled van has not been replaced. A record review of Resident #87's Admission Record revealed the facility admitted resident on 07/06/2022 with the diagnoses of Peripheral Vascular Disease (PVD), Post-Traumatic Stress Disorder (PTSD), and Depression. A record review of Resident #87's Quarterly MDS with an ARD of 04/05/2023 revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #87 was cognitively intact. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on observation, interview, record review, and facility policy review, the facility failed to develop or implement a comprehensive care plan for residents with a Supra-Pubic Catheter, diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), Range-of-Motion (ROM) related to an Orthopedic Brace, Treatment related to a Vascular Implant, and Orthopedic, Wound and Vascular Appointments for five (5) of 24 care plans reviewed. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's failure to develop or implement a Comprehensive Care Plan which resulted in decreased mobility for Resident #31, hospitalization for Resident #75, a wound infection for Resident #87, and sepsis for Resident #254. There was a likelihood of harm for Resident #34 due to a delay in changing a supra pubic catheter. The facility's failure to develop or implement care plan interventions placed these residents, and other residents who are at risk in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21 (b)(1)(i) Comprehensive Care Plan, F656 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's Policy, Plans of Care revised 9/25/2017, revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing .needs that are identified in the comprehensive assessment .Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes .The Individualized Person Centered plan of care may include but is not limited to the following .Services to attain or maintain the resident's highest practicable physical, mental .well-being as required by state and federal regulatory requirements . Resident #75 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #75 that included measurable objectives and timetables to meet the resident's medical or nursing needs related to the resident's diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date of 3/29/23, revealed Resident #75 had Active Diagnoses including Heart Failure and Respiratory Failure and had additional active diagnoses of Chronic Obstructive Pulmonary Disease. Record review of the Admission Record revealed the facility admitted Resident #75 on 9/12/22 and she had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Diastolic Congestive Heart Failure. Resident # 31 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #31 to meet the resident's medical or nursing needs to address his left lower leg related to Range of Motion, his [NAME] brace and Othropedic appointments. A record review of the Admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. Resident #34 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #34 that included measurable objectives and timetables to meet the resident's medical or nursing needs related to a newly placed suprapubic catheter. Record review of the Procedure Note, dated 3/24/23, revealed Resident #34 had a procedure for .placement of 16 french SPT (Suprapubic Tube) . Record review of the Admission Record revealed the facility admitted Resident #34 on 06/22/2020 with a diagnosis of Spina Bifida. Resident #87 Record review of the Comprehensive Care Plan with a Focus of The resident has a surgical wound of the left thigh R/t (related to) infected graft wound revealed Resident #87 had an Intervention/Tasks of Administer treatments as ordered . Record review of the Order Summary Report dated 5/3/23, revealed Resident #87 had a Physician's Order, dated 11/21/22, for refer to (Proper Name of Physician) vascular surgeon at (Proper Name of Medical Clinic), a Physician's Order, dated 3/17/23, for Get appointment with physician at (Proper Name of Medical Clinic) .ASAP (as soon as possible) .related to Unspecified Open Wound, Left Thigh ., and a Physician's Order, dated 4/11/23, for Get appointment with (Proper Name of Physician) vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh . A record review of the Admission Record revealed the facility admitted Resident #87 on 07/06/2022, and he had diagnoses including Post-Traumatic Stress Disorder (PTSD) and Depression. Resident #254 Record review of the Comprehensive Care Plan with a Focus of The resident has a (stage 4) pressure injury (sacrum) r/t disease process . revealed Resident #254 had Intervention/Tasks of Administer treatments as ordered . Record review of the Progress Notes for Resident #254 revealed a Nursing Progress Note dated 4/14/23 at 13:53 (1:53 PM) for unable to take resident to wound care apt (appointment) today will contact family and wound care to reschedule. Record review of the Admission Record revealed the facility admitted Resident 2354 on 4/14/22 with diagnoses including End Stage Heart Failure and Type 2 DM. During a phone interview on 05/05/23 at 02:50 PM, with RN, #2, who is the MDS/Care Plan nurse, she stated that she no longer worked for the facility as of 5/4/23. She explained there had always been three (3) nurses in the MDS/Care Plan office, but since the end of last year (2022), she had been in the office alone and had to complete all the care plans and the MDS assessments for the residents. RN #2 said that she was out in December and had not been able catch up with all the care plans. RN #2 said that at the end of March 2023, another nurse was hired for the MDS/Care Plan office, but both have had to work the floor and cart and have not been able to get caught up on all the care plans. RN #2 explained the purpose of the care plans was to provide a plan of care for the residents and she expected the staff to follow the care plans as indicated to provide residents with quality care and to meet their needs. RN #2 confirmed all residents should have individualized care plans to meet their needs. During an interview on 05/05/23 at 03:30 PM, with the Director of Nursing (DON), she said that due to staffing issues, both the MDS/Care Plan nurses have had to work the floor and cart lately. She explained she expected all staff members to develop and follow the care plans to meet the needs of all residents. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. ) The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident received necessary treatment and services to promote the healing of a pressure ulcer and prevent an infection for one (1) of two (2) residents reviewed for pressure wounds. Resident #254 Findings include: A record review of the facility's policy Skin and Wound, with a revision date of 01/24/2022 revealed, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries. Process: . Skin Impairment Identification: . 4. Refer to Therapy as appropriate. 5. Monitor residents' response to treatment, modify as indicated . On 05/03/23 at 10:10 AM, during an interview with the Wound Care Nurse/Registered Nurse (RN) #1, she explained Resident #254 was sent to the hospital from the wound care appointment on 04/19/2023 and remains in the hospital. She revealed she had referred Resident #254 to the local hospital wound clinic, due to a large infected sacral wound. She stated Resident #254 had previously been scheduled for a wound care appointment on the 14th of April, but due to lack of transportation, the appointment was rescheduled for 04/19/2023. On 05/04/23 at 08:50 AM, during a telephone interview with Resident #254's Resident Representative (RR), he explained since admission to the facility, the resident has been hospitalized several times for wound infections. The RR revealed the resident's wounds would improve during the hospitalization , however, when she returned to the facility, the wounds would always get worse. On 05/04/23 at 09:10 AM, during a telephone interview with Resident #254's niece, she explained the resident is in the hospital and the wounds are being treated. The niece complained the facility has not been taking good care of the resident and that she had even taken pictures of the resident's wound dressings, showing that they had not been changed in a couple of days. The niece revealed that as the resident's wounds continued to worsen, she had tried to talk to the Director of Nurses (DON), wound care nurse, and the floor nurse about her concerns, no one would talk to her, and everyone blamed each other. On 05/04/2023 at 10:15 AM, during an interview with the Director of Nursing (DON), she confirmed Resident #254 did acquire wounds in the facility and that the wounds continued to deteriorate. She confirmed Resident #254 was transported to the wound care clinic via ambulance on 04/19/2023. On 05/04/23 at 10:50 AM, during an interview with RN #1/Wound Care Nurse, she confirmed Resident #254 missed her first wound care clinic appointment on 04/14/2023 due to facility transportation problems of not having a van to take the resident. She confirmed Resident #254's wound on her sacrum started out very small but has now progressed to a large wound, with large amounts of drainage, and wound stayed infected. She confirmed Resident #254 had asked to go to the hospital on 04/14/2023 but was not sent until 04/19/2023 for a wound care clinic appointment. On 05/05/23 at 01:45 PM, during an interview with the DON, she explained the facility has no records of the resident's visit to the (Proper Name Wound Care Clinic) because when she phoned the clinic, she was informed the clinic has no documentation on the visit, as upon arrival to the clinic, the patient was lethargic and when vitals were taken, the resident went straight to the emergency room . On 05/08/23 at 11:10 AM, during a telephone interview with the local wound care clinic, the clinic staff explained when Resident #254 arrived for the wound appointment, her vital signs were taken, and the resident was immediately sent to the Hospital emergency room , as the resident had an elevated temperature and was lethargic. Record review of Resident #254's Admission Record revealed the facility initially admitted the resident on 03/22/2021 and readmitted on [DATE] with the diagnoses of End Stage Heart Failure, Schizophrenia, Unspecified, and Type 2 Diabetes Mellitus without Complications. Record review of Resident #254 Order Summary Report dated 05/03/2023 revealed, orders for . consult (Proper Name Wound Care) for worsening of Stage 4 to sacrum with order date 04/10/2023 and an order dated 04/14/2023 revealed, wound care clinic apt (appointment) rescheduled to 04/19/2023 at 08:30 AM . A record review of Resident #254's Progress Notes *NEW* dated 05/05/2023 revealed on 04/14/2023 at 01:53 PM . unable to take resident to wound care apt (appointment) today will contact family and wound care to reschedule . with author RN#1. A note dated 04/14/2023 at 06:40 PM revealed . nurse . educated the resident on the importance of allowing the facility to take care of her wounds and start her on antibiotics . resident refused stating she doesn't trust anyone here she wants the hospital to give her the antibiotics . Progress note dated 04/19/2023 at 09:30 AM revealed . Res (resident) transferred to hosp (hospital) per Proper Name (ambulance) via stretcher at this time for wound care appt (appointment) . A record review of Resident #254's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2023, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Section M revealed Resident #254 had two (2) Stage 2, one (1) Stage 4, and two (2) Unstageable pressure wounds. A record review of Resident #254's Pressure Ulcer Wound Rounds dated 04/07/2023 and 04/13/2023 revealed effective date 04/07/2023 at 12:12 PM sacrum pressure wound had measurements 15.6 centimeters (cm) length x width 12.9 cm x depth 3.9 cm Stage IV had wound bed with slough that was yellow in color with a large amount of yellow purulent drainage with odor. Assessment with effective date 04/13/2023 at 01:18 PM revealed sacrum pressure wound had measurements of 18.0 cm x 16.6 cm and 0.5 cm Stage IV and continued to have a wound bed with yellow slough in color with a large amount of yellow purulent drainage with odor. By comparison, of the last two (2) assessments of the Stage IV sacrum revealed the wound had continued to increase in size. A record review of Resident #254's hospital records dated 04/19/2023, with a chief complaint of Decubitus ulcer revealed .The patient is a nursing home resident. She went to wound care and she was found to be tachycardic (high heart rate) and febrile (had a fever). Patient was sent to ER (emergency room ). The patient is complaining of pain in her wounds . In the ER, the patient was hypotensive (had low blood pressure), tachycardia, and tachypneic (breathing fast). Her work-up cell count was 24,000. She was admitted . A: Sepsis secondary to multiple decubitus ulcers . P. Unstageable sacral decubitus ulcer 20 x 30 centimeters in area. Wound culture of her sacral decubitus ulcer is ordered. Cultures are taken x2. General surgery is consulted for debridement .

Based on observations, interviews, record review and facility policy review, the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility, on 2/11/22 at approximately 12:30 PM. This concern was identified for one (1) of three (3) residents reviewed for wandering behaviors and at risk for elopement. Resident #1. Resident #1 was identified by the facility as an elopement risk related to his history of attempts to leave the facility unattended, impaired safety awareness, and confusion. Resident #1 was wearing a Wander Guard device and exited the facility from the front entrance door after a default code was entered by the staff. The default door code allowed the door to remain unlocked for a longer period than the regular door code and prevented the Wander Guard device from alarming. Resident #1 was missing, unsupervised and away from the facility for approximately 23 minutes until he was found in a ditch by a local tire shop owner who reported it to the police. The facility staff did not know Resident #1 was off the facility grounds until they were notified by a paramedic with the local ambulance service and a Police Officer brought a photograph of the resident to the facility for identification. The local Police Department informed the nursing home staff that Resident #1 was taken to the local emergency room to be assessed for injuries. Resident #1 was later returned to the facility by the local ambulance company. The facility failed to provide adequate staff supervision for Resident #1, who was an elopement risk with a current display of wandering behaviors, placed this resident and all other residents who exhibit wandering behaviors at risk with a likelihood for serious injury, harm, impairment or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) identified on 2/23/22, which occurred on 2/11/22 and existed at 42 CFR(s): 483.25(d)(1)(2)-Free of Accidents, Hazards/Supervision/Devices (F689) Scope and Severity J. Based on the facility's implementation of corrective actions on 2/11/22, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed 2/12/22 prior to the SA's entrance on 2/18/22. The SA notified the facility's Administrator of the PNC IJ and SQC on 2/23/22 at 3:40 PM and presented the IJ Template. Findings include: Record review of the facility's policy, Elopement/Wandering Risk Guideline, revised 8/01/2020 revealed, Overview: To evaluate and identify patients/residents that are at risk for elopement and develop individualized interventions. Process: Patients/Resident's to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, an elopement event using the risk tool. If a patient/resident is identified as being at risk the staff should complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on the patient/residents' risk. Document individualized interventions in the resident's care plan and Kardex. If they do a wander monitoring system device check placement of the device every shift and functionality every day. Maintain the elopement risk alerts in an easily accessible location. Complete routine elopement drills monthly and reviewed in Quality Assurance and Performance (QAPI) meetings . Record review of the facility's policy, Elopement Risk, dated 11/30/2014 revealed, Policy: It is the policy of The Company that on admission and quarterly, all residents will be assessed for elopement risk. Procedure: An elopement risk assessment will be completed on admission and quarterly by nursing. If the resident is identified as an elopement risk based on the assessment, the care plan will reflect the intervention (i.e., wander guard or code alert) and desired outcomes. Review and or revised care plan following an attempt to leave the facility. Resident identified as at risk for elopement will require nursing to check residents regularly and document on the Safety Checks . Record review of the facility's policy, Missing Patient/Resident, dated 11/30/2014 revealed, Overview: Staff will investigate cases of missing residents and possible elopement. An elopement occurs when a resident leaves the premises or a state area without authorization and or any necessary supervision to do so, placing the resident at risk for harm or injury . Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE]. Record review of the Diagnosis Report revealed Resident #1 had diagnoses that included Unspecified Dementia without Behavioral Disturbances and Alzheimer's Disease, unspecified. Record review of a quarterly Minimum Data Set (MDS) dated [DATE], Section C- Cognitive Patterns revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating Resident #1 had severe cognitive impairment. Section D- Mood revealed item H. Moving or speaking so slowly that other people could have noticed, or the opposite-being so fidgety or restless that you have been moving around more than usual. This section was marked with 1 which indicates symptoms were present and the symptom frequency was on 2-6 days. Record of the Resident #1's Elopement Risk Evaluation with an effective date of 12/29/21 revealed, .resident is determined to be AT RISK for elopement 1. yes . Record review of the facility's Timeline with the Date of Event of 2/11/22, revealed Date 2/11/22 Time 1215 (12:15 PM) Event Resident at the nurses station. Stated to staff that his sister was going to pick him up today and take him out for a while. Time 1230 (12:30 PM) Event Resident noted near the front lobby when transportation driver brought another resident back in from the van. Time 1253 (12:53 PM) Event Facility contacted by (Proper Name of local ambulance service) and notified that resident was noted outside of facility. No apparent injuries. Resident transported to ER for evaluation per (Proper Name of local ambulance service) protocol. Time 1255 (12:15 PM) Event (Proper Name of local police department) notified and at facility. 100% resident head count initiated. All other residents accounted for. Time 1255 (12:55 PM) Event MD Notified. Door alarm function checked per Maintenance Director. Time 1315 (1:15 PM) Event Transmitter placement and function verified by nursing staff. Time 1332 (1:32 PM) Event Social Services attempted to contact RP (Responsible Party). Time 1430 (2:30 PM) Reported to (State Agency) Reportable Incident Hotline Time 1530 (3:30 PM) Event IDT (Interdisciplinary Team) meeting held r/t (related to) incident, staff education initiated. Time 1600 (4:00 PM) Event Resident placed on one-on-one observation. 24/7 door monitoring initiated. Time 1638 (4:38 PM) AG (Attorney General) notified. Time 1643 (4:43 PM) Event Resident returned to facility. No injuries, no c/o pain. Resident able to verbalize and physically confirm area of exit from facility. New wangerguard placed to right ankle. Record review of a handwritten Witness Statement dated 2/11/22, revealed Name of Witness as Certified Nursing Assistant (CNA) #2. At about 12:30 me and (Proper Name of another Resident) was coming back from a doctor's appt. (appointment) When we came in the door (Resident #1) was standing by the table in the front lobby . On 2/18/22 at 1:20 PM through 1:25 PM, observation revealed there were an average of nine (9) cars counted traveling on the street in front of the facility every minute during a five (5) minute observation (approximately 45 cars). Observation of the area surrounding the facility revealed the street was approximately twenty-five (25) yards from the front door of the facility. There was a covered entry area approximately ten-foot square with a standard size sidewalk past the entry way. Past the sidewalk there was an intact [NAME] parking lot with parking spaces lining the sidewalk along the front of the building. Past the lined parking spaces was the circular driveway with two entrances. There was a drainage ditch which ran around the facility which was approximately ten to twelve feet deep and ran under the street through a culvert at the east corner of the property. There were no sidewalks, walking or bike lanes along the street in front of the facility. There was a paved area which measured six (6) feet wide between the edge of the street and a [NAME] strip in the street. On 2/18/22 at 2:50 PM, observation of the area in which Resident #1 was located 0.4 tenths of a mile from the facility in a ditch in front of the tire shop revealed there were an average of forty-seven (47) cars counted traveling on Highway 98 during a six (6) minute observation. The ditch was approximately three (3) feet deep with a smooth sloping surface. On 2/18/22 at 4:15 PM, a telephone interview with the Resident Representative (RR) for Resident #1 revealed the facility notified her of Resident #'1s elopement. She stated she was concerned about it, but not surprised by it. She stated her father had voiced a desire to leave the facilityand to get out of there since admission. She stated he had been identified as an elopement risk since admission but had not exited the building alone prior to this incident. She stated she was concerned about how he could have exited if he had been wearing a 'Wander Guard' bracelet. During an interview on 2/23/22 at 09:00 AM, with the Maintenance Director revealed staff must input a door code which allows the door to open to enter the building. The Maintenance Director confirmed that staff used an override code, which prevented the door alarm from sounding when a resident wearing a Wander Guard device approached the door and allowed the door to remain unlocked for a longer period. The Maintenance Director identified the override code as being the incorrect code for staff to use to open the door. The staff should have used the regular code, which would have caused the door to immediately lock when the door closed. It would also sound an alarm when a resident with a Wander Guard device approached the door. The Maintenance Director said he does not know how the staff got the override code and he was not aware that all the staff was using the override code instead of the regular code until the elopement occurred and it was discovered during the investigation. The old override code was permanently disabled and the new override code is only known to himself and the Administrator. During an interview on 2/23/22 at 9:15 AM with the Director of Nursing (DON), she stated she was notified by the local ambulance service that a resident was found in the ditch and was taken to the emergency room to be assessed. The DON stated that a local Police Officer came to the facility with a picture of the resident asking if this resident lived at this facility and she confirmed that he did. The local Police Officer advised her that the resident was taken to the emergency room via ambulance to be assessed for injuries and Resident #1 had been found at the corner of the street. The DON stated that the facility immediately completed a head count and all doors and windows were checked. The DON immediately started an investigation and received statements from all the staff. During the investigation, the DON learned that the Screener and the Receptionist said the resident was standing by the front entrance at 12:30 PM. The investigation determined Resident #1 left through the front entrance door because staff and visitors were coming in and out of the door. The DON confirmed after investigating and getting statements from the staff, the facility realized the staff were using the wrong code to enter and exit the building. This caused the door alarm not to sound when Resident #1 approached the door. During an interview on 2/23/22 at 9:30 AM, with the local Police Officer revealed the Police Department received a call from a local business owner stating that an elderly man had fallen in the ditch and had been there for a long time. The local business owner stated that the man could not get up out of the ditch. A police officer came to the scene and took pictures of the resident. The officer notified the local ambulance service to assess the resident and he was transported to the local emergency room (ER) to be assessed for injuries per ambulance protocol. During an interview on 2/23/22 at 10:00 AM, with a local Business Owner, he stated that he saw Resident #1 sitting in the ditch and he had been sitting there for a long time. He was unsure how long the resident had been there, but it didn't look like he could get up without assistance, so he called the local Police Department and they responded quickly. During an interview with the Paramedic on 2/23/22 at 11:00 AM, she confirmed that she received a call from the local Police Department stating that an elderly male was found in the ditch next to a local business. The Paramedic said she arrived at the scene and noticed Resident #1 sitting in the ditch and that she remembered seeing Resident #1 about 20 or 30 minutes ago walking around in the parking lot at the nursing home. She had thought the resident was a visitor that was visiting someone at the nursing home. The resident was wearing a light jacket with a T-shirt, blue jeans, and socks and shoes. He was walking on the heel of the shoes, wearing them as slides. The Paramedic asked the resident where he was going and he replied that he was running away from the nursing home and he was not going back. The Paramedic assessed Resident #1 and did not see any bruising or signs of broken bones, so he was transported to the emergency room for a wellness exam. The Paramedic stated that they called the nursing home facility and asked if there was a resident missing and the nursing home did not know if there were any residents missing at that time. The local Police Officer took a picture of Resident #1 and went to the nursing home. During an interview on 2/23/22 at 11:30 AM, with the Social Services Director (SSD), she confirmed Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) on his last Minimum Data Set (MDS) assessment, which indicated severe cognitive impairment. The SSD conducted a BIMS when Resident #1 returned to the facility after the elopement and he scored a 7 which still indicated severe cognitive impairment. The SSD said Resident # 1's BIMS score fluctuates. The SSD said Resident #1 wanders all over the building, but he has never tried to exit the facility or had made statements of wanting to leave. The SSD stated that Resident #1 was upset because his daughter had not come to see him for several weeks. An interview on 2/23/22 at 11:45 AM, with the Speech Therapist (ST) revealed the DON asked her to conduct a Brief Cognitive Assessment Tool (BCAT) on Resident #1 when he came back to the facility. The ST said the Resident scored a 27 out of 50, which indicated Resident #1 was mildly demented. On 2/23/22 at 12:15 PM, in an interview with CNA # 4 revealed she is the Receptionist and was working the day of the elopement. She stated that she was stamping receipts and had her head down when the elopement occurred. CNA #4 stated the last time she saw Resident #1 he was standing in the front lobby entrance interacting with visitors and staff. She did not see the resident exit the building. On 2/23/22 at 12:45 PM, in an interview with CNA #2 stated on 2/11/22 around 12:30 PM she arrived from taking another Resident to a doctor's appointment, when she noticed Resident #1 standing in the front entrance. Resident #1 smiled and continued to stand in the lobby. CNA #2 said she looked back at the door to make sure it locked and took the Resident to her room. Record review of Resident #1's Change in Condition (SBAR) (Situation Background Assessment and Recommendation), with an effective date of 2/11/22, revealed .A. Situation 1. The change in condition, symptoms, or signs observed and evaluated is/are: resident noted to be out of facility unattended by (Name of Local Ambulance Company) staff. resident transported to ER for eval. (evaluation). no visible injuries noted EMT (Emergency Medical Technician). no c/o (complaints of) pain. Told EMT 'I'm gonna leave every chance I get' .B. Appearance 1. Summarize your observations and evaluation: resident returned to facility from ER. no skin impairments noted. New Wander guard placed on right lower leg. functionality of device checked. resident placed on one-on-one until further notice . Record review of the Order Summary Report with active orders as of 2/11/22 revealed an order with an order and start date of 10/12/21 Monitor wander guard (right wrist) for placement and function q (every) shift . Record review of the February 2022 Treatment Administration Record (TAR) revealed Monitor wander guard (right wrist) for placement and function q (every) shift exp (expiration) date 6/2024 discontinued 2/11/22. Monitor wander guard (right leg) for placement and function q shift (exp. date 12/2024) every day and night shift for monitoring, start date 2/11/22. Record review of Resident #1 's comprehensive care plan revised 10/20/21 revealed, Focus: The resident is an elopement risk r/t (related to) history of attempts to leave facility unattended, impaired safety awareness, confusion .Interventions: .Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Resident prefers. Electronic monitoring device. Check Wanderguard for PLACEMENT AND FUNCTIONING AS ORDERED. Nurse to check to assure Wander guard bracelet is in place every shift. Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan /Corrective Actions prior to the State Agency (SA) entrance on 2/18/22. In response to the past Noncompliance IJ and SQC cited at 3:40 PM on 2/23/22, the facility submitted a summary of the event, including an IJ removal plan and corrective actions, taken by the facility to remove the IJ. Brief Summary of Events: At 3:40 PM on February 23, 2022, the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy, which began on February 11, 2022, related to the facility's failure to provide supervision for Resident #1 who left the facility unnoticed and unsupervised on February 11, 2022 at approximately 12:30 PM and was located approximately 23 minutes after the last observation by a staff member. An immediate jeopardy (IJ) template was provided to the ED by the SA. The IJ was cited Past Noncompliance (PNC). On February 11, 2022, at approximately 12:53 PM Emergency Service personnel (EMS) #1 called the facility and notified the Director of Nursing (DON) that, while in route back to EMS headquarters, Resident #1 was found approximately 400 feet from the nursing facility. Resident #1 was in route to emergency room (ER). Corrective Actions: 1. On February 11, 2022, at 12:55 PM Resident #1's primary physician was notified by DON. Responsible Party was notified at 1:32 PM by Social Services Director (SSD). Attorney General was notified at 4:38 PM by Assistant Director of Nursing (ADON). SA was notified at 2:30 PM by ADON. 2. On February 11, 2022, at 12:55 PM a visual headcount was initiated and completed at 1:00 PM by Licensed Practical Nurse #1, #2, #3, #4 and #5. Census on February 11, 2022, was 104. 103 residents were accounted for and noted to be in the facility. Resident # 1 remained in the ER at the time the visual headcount was completed. 3. On February 11, 2022, at 1:00 PM the Maintenance Supervisor (MS) validated that all 10 exit doors were functioning appropriately. Wander guard system at front door was functioning appropriately and door was opening and closing appropriately. 4. On February 11, 2022, at 1:15 PM LPN #1, #2, #3, #4 and #5 initiated validation of placement and function of wander guard devices, using visual observation and device transmitter, for residents currently residing in the facility who were previously identified as elopement risks. Placement and function validation was completed at 1:30 PM and documented in the electronic health record. Wander guard devices were noted to be appropriately placed and functioning. 5. On February 11, 2022, at 3:30 PM the ADON initiated education with current employees on the topics of Elopement Guideline, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring & Elopement Drill, and proper door code to exit facility. Education provided prior to the start of each employee's next scheduled shift. No employee will be a allowed to work without education. 6. On February 11, 2022, at 3:30 PM the Quality Assurance Performance Improvement (QAPI) Committee met to review the investigation, conduct the Root Cause Analysis (RCA) and review policy and procedures for any changes. Attendees of the QAPI Committee meeting included the ED, DON, SSD, Housekeeping Supervisor (HKS), Human Resources Director (HRD), Medical Records Clerk (MRC), Therapy Director (TD), Activities Director (AD), Dietary Manager (DM), and Medical Director (MD) . The RCA determined Resident #1 exited the front entrance door unnoticed and unsupervised by staff. The RCA also determined staff were using an override/ default door code that prevented the wander guard system from engaging alarms on door when wander guard device was in proximity of door. Policy and procedures for Elopement Guidelines, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring and Elopement Drill, and proper door code to exit facility were reviewed and no changes to policy and procedures were made. 7. On February 11, 2022, at 4:00 PM there was a staff member put to monitor door continuously. There was a door monitor on the door until February 15, 2022, at 3:00 PM. 8. On February 11, 2022, at 4:15 PM Elopement Drills were initiated and conducted by the DON and MS with 15 employees and education was provided on Elopement Guidelines, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring & Elopement Drill, and proper door code to exit facility. 9. On February 11, 2022, at 4:40 PM Resident #1 returned to the nursing facility by an ambulance transport. There was no injury reported. Resident #1 was placed on one on one observation upon return. Complete body audit was completed by DON and ADON at 4:43 PM. No injury noted. Resident #1's care plan was reviewed and updated to reflect new interventions. 10. On February 11, 2022, at 4:46 PM the Social Services Director (SSD) completed a Brief Interview for Mental Status (BIMS) for Resident # 1. Resident's score was a 7 which indicates cognition was severely impaired. 11. On February 11, 2022, at 5:00 PM ADON initiated reevaluation of current Residents identified to be an elopement risk. Reevaluations were completed at 6:00 PM and residents reevaluated were determined to remain elopement risk. No additional residents were identified at risk for elopement. 12. On February 11, 2022, at 5:30 PM Maintenance Supervisor (MS) #1 notified Vendor #1 to remove override code from wander guard system. The override code only affected the function of front door entrance. The override code was permanently disabled and verified by MS #1. Per Maintenance interview, he and the Administrator have an override code? 13. On February 11, 2022, at 6:00 PM the DON and ADON elopement binders were reviewed to ensure they contained current Residents at risk for elopement's identifying information. All elopement binders contained no issues. 14. On February 11, 2022, at 10:45 PM Resident #1 was reevaluated for elopement risk by the Assistant Director of Nursing (ADON). Based on potential risk factors Resident continues to be at risk for elopement. 15. On February 12, 2022, at 5:30 AM, an additional Elopement Drill was conducted by the DON and MS with 17 employees and education was provided on Elopement Guideline, Missing Resident Search, Elopement Assessment, and Wander Guard Monitoring & Elopement Drill. 16. On February 12, 2022, between 7:56 AM and 10:27 AM the Speech Therapist (ST) conducted a Brief Cognitive Assessment Tool (BCAT). Resident #1 scored 27 out of 50 which indicates mild Dementia. Based on results physician orders noted for Speech therapy 3 x weekly for 4 weeks to focus on reasoning skills related to safety awareness. Resident #1's care plan was updated to reflect ST's observations and interventions. The facility alleges all corrective action to remove the immediate jeopardy was completed as of February 11, 2022, and the immediate jeopardy was removed February 12, 2022. Validation: The SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, interviews and record reviews. 1. The SA validated through interview and record review that on February 11, 2022, at 12:55 PM Resident #1's primary physician was notified by DON. Responsible Party was notified at 1:32 PM by Social Services Director (SSD). Attorney General was notified at 4:38 PM by Assistant Director of Nursing (ADON). SA was notified at 2:30 PM by ADON. 2. The SA validated through interviews and record review that on February 11, 2022, at 12:55 PM a visual headcount was initiated and completed at 1:00 PM by Licensed Practical Nurse #1, #2, #3, #4 and #5. Census on February 11, 2022 was 104. 103 residents were accounted for and noted to be in the facility. Resident # 1 remained in the ER at the time the visual headcount was completed. 3. The SA validated through observation, interviews, and record reviews that on February 11, 2022, at 1:00 PM the Maintenance Supervisor (MS) validated that all 10 exit doors were functioning appropriately. Wander guard system at front door was functioning appropriately and door was opening and closing appropriately. 4. The SA validated through observation, interviews and record review that on February 11, 2022, at 1:15 PM LPN #1, #2, #3, #4 and #5 initiated validation of placement and function of wander guard devices, using visual observation and device transmitter, for residents currently residing in the facility who were previously identified as elopement risks. Placement and function validation was completed at 1:30 PM and documented in the electronic health record. Wander guard devices were noted to be appropriately placed and functioning. 5. The SA validated through interview and record review that on February 11, 2022, at 3:30 PM the ADON initiated education with current employees on the topics of Elopement Guideline, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring & Elopement Drill and proper door code to exit facility. Education provided prior to the start of each employee's next scheduled shift. No employee will be allowed to work without education. 6. The SA validated through interviews and record review that on February 11, 2022, at 3:30 PM the Quality Assurance Performance Improvement (QAPI) Committee met to review the investigation, conduct the Root Cause Analysis (RCA) and review policy and procedures for any changes. Attendees of the QAPI Committee meeting included the ED, DON, SSD, Housekeeping Supervisor (HKS), Human Resources Director (HRD), Medical Records Clerk (MRC), Therapy Director (TD), Activities Director (AD), Dietary Manager (DM), and Medical Director (MD) . The RCA determined Resident #1 exited the front entrance door unnoticed and unsupervised by staff. The RCA also determined staff were using an override/ default door code that prevented the wander guard system from engaging alarms on door when wander guard device was in proximity of door. Policy and procedures for Elopement Guidelines, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring and Elopement Drill, and proper door code to exit facility were reviewed and no changes to policy and procedures were made. 7. The SA validated through observation, interviews, and record review that on February 11, 2022, at 4:00 PM there was a staff member put to monitor door continuously. There was a door monitor on the door until February 15, 2022 at 3:00 PM. 8. The SA validated through interviews and record review that on February 11, 2022, at 4:15 PM Elopement Drills were initiated and conducted by the DON and MS with 15 employees and education was provided on Elopement Guidelines, Missing Resident Search, Elopement Assessment, Wander Guard Monitoring & Elopement Drill, and proper door code to exit facility. 9. The SA validated through interviews and record review that on February 11, 2022, at 4:40 PM Resident #1 returned to the nursing facility by an ambulance transport. There was no injury reported. Resident #1 was placed on one-on-one observation upon return. Complete body audit was completed by DON and ADON at 4:43 PM. No injury noted. Resident #1's care plan was reviewed and updated to reflect new interventions. 10. The SA validated through staff interview and record review that on February 11, 2022, at 4:46 PM the Social Services Director (SSD) completed a Brief Interview for Mental Status (BIMS) for Resident # 1. Resident's score was a 7 which indicates cognition was severely impaired. 11. The SA validated through record review that on February 11, 2022, at 5:00 PM ADON initiated reevaluation of current Residents identified to be an elopement risk. Reevaluations were completed at 6:00 PM and residents reevaluated were determined to remain elopement risk. No additional residents were identified at risk for elopement. 12. The SA validated through interview and record review that on February 11, 2022, at 5:30 PM Maintenance Supervisor (MS) #1 notified Vendor #1 to remove override code from wander guard system. The override code only affected the function of front door entrance. The override code was permanently disabled and verified by MS #1. 13. The SA validated through record review that on February 11, 2022, at 6:00 PM the DON and ADON elopement binders were reviewed to ensure they contained current Residents at risk for elopement's identifying information. All elopement binders contained no issues. 14. The SA validated through record review that on February 11, 2022, at 10:45 PM Resident #1 was reevaluated for elopement risk by the Assistant Director of Nursing (ADON). Based on potential risk factors Resident continues to be at risk for elopement. 15. The SA validated through record review that on February 12, 2022, at 5:30 AM, an additional Elopement Drill was conducted by the DON and MS with 17 employees and education was provided on Elopement Guideline, Missing Resident Search, Elopement Assessment, and Wander Guard Monitoring & Elopement Drill. 16. The SA validated through interview and record review that on February 12, 2022, between 7:56 AM and 10:27 AM the Speech Therapist (ST) conducted a Brief Cognitive Assessment Tool (BCAT). Resident #1 scored 27 out of 50 which indicates mild Dementia. Based on results physician orders noted for Speech therapy 3 x weekly for 4 weeks to focus on reasoning skills related to safety awareness. Resident #1's careplan was updated to reflect ST's observations and interventions. Review of the Facility's educational in-service record, dated 2 /11/22, revealed the facility provided all the staff and in- service on elopement which included following orders for visual checks /monitoring resident location, function of wander guard per orders, answering alarms in a timely manner, and door/wander guard alarms.

Based on record review, policy review, interview, and observation, the facility failed to develop a care plan to ensure the supervision and safety of Resident #1 with exit seeking behaviors. This was for one (1) of six (6) residents sampled for wandering. The facility's failure to develop a comprehensive care plan resulted in Resident #1 exiting the facility without supervision and without staff knowledge on 12/01/14. Resident #1 ambulated three-tenths (.3) of a mile from the facility and was returned to the facility by an off duty, Certified Nurse Aide (CNA). The facility's failure to develop a resident care plan after the resident ambulated to facility doors and made statements of wanting to get out of the facility had the likelihood to result in serious injury, harm, impairment, or death to Resident #1 and other residents assessed for wandering. This situation was determined to be an Immediate Jeopardy (IJ) which began on 11/28/14. The facility's Administrator was notified of the IJ on 12/09/14. An acceptable credible Allegation of Compliance was received on 12/11/14 in which the facility alleged the Immediate Jeopardy was removed on 12/11/14. The State Survey Agency determined the IJ was removed on 12/12/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (k) (1) (F279), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systematic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The undated facility policy entitled, "Care Plan," revealed, "An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis." This policy further stated, "The Interdisciplinary Team is to review the 24-Hour Report daily for significant changes or changes in resident's ADL (Activity of Daily Living) status. The Interdisciplinary Team will add minor changes in resident's status to the existing Care Plans on an as needed basis." During interview with Registered Nurse (RN) #4 on 12/11/14 at 10:45 AM, RN #4 confirmed she served as the Minimum Data Set (MDS) coordinator and completed resident care plans. RN #4 stated Resident #1 did not have a care plan identifying him at risk for elopement or as requiring supervision for exit seeking behaviors until he was returned to the building on 12/01/14 by CNA #1. RN #4 revealed she was unaware of Resident #1 being at risk for elopement prior to his leaving the building on 12/01/14, and was unaware of Resident #1's exit seeking behavior on 11/28/14. RN #4 stated nurses on each unit could update a care plan immediately when a need was identified. RN #4 explained when she was notified of a change during the morning meeting or at the scheduled assessment, she made the changes to the care plan. Review of Resident #1's Nurses' Notes revealed Licensed Practical Nurse (LPN) #1 documented Resident #1 exhibited exit-seeking behaviors by wandering about the facility looking for a way to leave. Documentation revealed on 11/28/14 Resident #1 wandered off his unit in the facility and was returned to the nursing unit by CNA #4. During an interview with CNA #4 on 12/11/14 at 4:07 PM, CNA #4 confirmed he brought Resident #1 back to resident's unit on 11/28/14 after finding Resident #1 walking around the facility. CNA #4 stated, "I told the nurse, when (LPN #1 name) came on, to keep an eye on him because he was rambling around there." Interview with LPN #1 on 12/10/14 at 10:02 AM, LPN #1 confirmed CNA #4 brought Resident #1 back to the hall and informed her the resident was at front door of the facility. LPN #1 confirmed she failed to inform the Unit Manager or any other staff after documenting exit-seeking behavior in nurse's notes for Resident #1. LPN #1 confirmed no elopement/wandering care plan was added at this time to Resident #1's care plan. The facility failed to develop a plan of care for Resident #1 following observed behaviors on 11/28/14 and on 12/01/14 prior to the elopement when Resident #1 was observed attempting to leave the facility again. This resulted in Resident #1 leaving the facility without staff knowledge and without supervision on 12/01/14. Resident #1 ambulated three-tenths (0.3) of a mile from the facility and was returned by CNA #1. Interview with CNA #2 on 12/08/14 at 1:24 PM, CNA #2 confirmed on 12/1/14 between 12:15 PM and 12:30 PM, CNA #2 stopped Resident #1 from exiting front door of facility and contact the Unit Manager, RN #1 regarding Resident attempting to leave the building, and suggested he needed a wander guard. CNA #2 confirmed just prior to 3:00 PM (unable to recall exact time) on 12/01/14, she observed Resident #1 again at the front exit door of the facility attempting to exit and she redirected Resident #1 again. Interview with RN #1 on 12/08/14 at 12:49 AM, RN #1 confirmed CNA #2 contacted her around 12:30 PM on 12/01/14 and reported Resident #1 had attempted to leave. RN #1 confirmed no changes in Resident #1's plan of care were initiated at this time. Review of Resident #1's care plan revealed a plan of care was developed for Resident #1 being at risk for elopement on 12/01/14 after the resident eloped from the facility. The facility admitted Resident #1 on 11/05/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/14 revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognitive status. No wandering or changes in behavior were documented as observed. Resident #1 was assessed as ambulatory with independent ambulation. The facility submitted an acceptable credible Allegation of Compliance on 12/11/14 for the Immediate Jeopardy. Review of the facility's Allegation of compliance revealed the facility took the following actions to remove the Immediate Jeopardy. 1. On 12/01/2014 at approximately 3:45 p.m. CNA#1 called stating she was bringing Resident #1 back to the facility as she had picked him up in her neighborhood. CNA#3 notified the administrator Resident #1 was in parking lot with CNA#1. The administrator called the DON and Unit Nurse Manager of hall where resident resides to her office. The DON and Unit Nurse Manager of hall where resident resides went outside to assist with getting Resident #1 back into the building. 2. He was returned to the nurses' station of the hall where resident resides at approximately 4:00 PM. He was assessed with [REDACTED]. observation and care plan created to show elopement risk. RP and MD were notified at this time. 3. The alternate physician #1 responded to the call giving ok for wander guard and order was given to send to the local hospital on the morning of 12/02/2014. MD states that he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. On December 1, 2014, an audit for elopement risk was done on entire resident census of 130 residents to identify other residents that have the potential to be affected. This audit was performed by DON, ADON, and Unit Managers. Of the 130 residents assessed, 7 residents were identified including resident number #1 at risk for elopement. 7 out of 7 care plans were reviewed including Resident #1 who required a new care plan for elopement. No other updates to care plans were needed at this time. 5. On 12/01/2014, in-service of staff began at 4:30 PM and continued until 12/10/ 14 at 9:30 AM by the DON (Director of Nurses) and ADON (Assistant Director of Nurses) to educate all full time RN, LPN's, CNA's, Housekeeping, Laundry, Maintenance, Activities, Social, Therapy, Dietary, Human Resources, Central Supply and Administration. 165 employees were in serviced by 12/10/2014 at 9:30 AM. 5 PRN (as needed) employees were unable to be reached. Those employees were taken out of the payroll system, a certified letter mailed to them and they will not be allowed to return to work until they have been in serviced. New hires will be inserviced before they begin to work. In service includes Policy # N-1031 Guide to Elopement Risk Assessment which covers risk factors which may cause a resident to be at risk for elopement and Policy N -1030 Elopement Education which covers protocol for staff to follow in case of a missing resident. No staff will be allowed to return to work until in serviced. 6. There are no contracted nurses employed at this facility. 7. The education content included our new internal protocol which states that that all staff is responsible for monitoring our residents and ensuring where they are and they are safe. This includes all disciplines. If a resident is a potential for elopement, nursing must be notified so that the resident can be properly assessed for a wander guard. If a change is noticed in a resident such as increased confusion, exit seeking, etc., nursing must also be notified and the resident must be placed on 1 on 1 observation until a registered nurse can assess and determine the cause of the new behavior. An RN should also assess resident for wander guard and if warranted, place wander guard on resident immediately, if no RN in building, staff will notify DON immediately and resident will remain on 1 on 1 until that time. It was reiterated that if you notice a change in your resident such as exit seeking, notify nurse immediately. Do not leave resident unattended until that nurse has resident and RN is assessing them to determine what is going on. Resident must remain supervised until staff can determine cause or place wander guard on resident. Employees have been instructed on the elopement policies and new internal protocol which was initiated on 12/1/2014. Employees understand that failure to follow policy/protocol could result in the potential for neglect. No staff will be allowed to return to work until in serviced. 8. On 12/02/2014 all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. All 8 doors and alarms were working properly. 9. On 12/02/2014 elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. An emergency QA meeting was conducted to review this incident on 12/02/2014 3:00 PM to include the Medical Director, ED, DON, ADON, 2 CNA's (certified Nursing Assistants), Unit Managers, Social Worker, Maintenance and Receptionist. The topic discussed was the elopement and the resident's medical record was reviewed. The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. We reviewed audits of elopement risks and the in-services that were given to the staff. The committee will review this issue within 30 days. 11. On 12/02/2104 at approximately 2:00 PM, a phone call was placed to MSDH (Mississippi State Department of Health), message left on voicemail. Investigative report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM. 12. The facility alleges immediate jeopardy was removed on 12/11/2014. On 12/12/14, the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. Interview with the DON and Unit Nurse Manager revealed as soon as they were notified of Resident #1's elopement, they went outside to assist with getting Resident #1 back into the building. 2. The state surveyor validated the resident was assessed with [REDACTED]. It was further validated, that Resident #1's Responsible Party and the alternate attending Physician were notified at this time. 3. Interview with the alternate attending physician#1 validated the order giving approval for a wander guard and an order was given to send to the local hospital on the morning of 12/02/2014. The physician stated he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. A review of the facility's audit for elopement risk validated 130 residents were audited with 7 residents identified to be at risk for elopement. The care plans for the 7 residents at risk were reviewed and updated as needed. 5. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheets provided by the facility's provided by the Director of Nursing and the Assistant Director of Nursing validated all staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants,Housekeeping, Laundry, Maintenance, Activities, Social Services, Therapy, Dietary, Human Resources, Central Supply and Administration. The State Agency validated that new employees and employees that could not be reached for inservice were taken out of the payroll system. The SA validated certified letters were mailed to the prn employees and they will not be allowed to return to work until they have been in serviced. 6. Review of Time Sheets and the working schedule validated the facility has no contracted nurses employed at this facility. 7. Review of the in-service content and sign in sheets related to the facility's new internal protocol which states that that all staff were in-serviced on responsibility for monitoring all residents and ensuring where they are and they are safe. This included all disciplines and all shifts. 8. Review of the Maintenance Directors records validated all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. The State Surveyor validated by observation of staff all 8 doors were functioning and the wander guard alarms were working. 9. A review of the Elopement Drill sign in sheets validated that elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. A review of the sign in sheet with content validated an emergency QA meeting was conducted on 12/2/14 at 2:00 PM which included the Medical Director, Administrator, DON, ADON, 2 CNAs, Unit Managers, Social Worker, Maintenance Director and the Receptionist. The topics discussed were the elopement and the new internal protocol The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. The Quality Assurance committee reviewed audits of elopement risks and the in-services that were in progress. 11. An interview with the facility Administrator validated the elopement had been reported to the state department of health on 12/02/2104 at approximately 2:00 PM, Phone call left on voicemail. The Investigative Report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM.

Based on policy review, complaint intake review, staff interview, and observation, the facility staff failed to promptly notify the physician and the responsible party for one (1) of six (6) residents sampled for elopement, Resident #1, after identifying a change in Resident #1's behavior on 11/28/14. On 12/01/14, Resident #1, left the facility without staff authorization, unattended, and without the knowledge of the facility staff. Resident #1 ambulated approximately three tenths (.3) of a mile from the facility on a busy city street. When the resident began exhibiting exit seeking behaviors by going to facility entrances and attempting to leave the facility on 11/28/14, the facility failed to notify the physician. This had the likelihood to result in serious injury, harm, impairment, or death to Resident #1 and other residents due to the lack of assessment and oversight by a physician after exit seeking behavior is identified. The facility's failure to notify the Responsible Party (RP) prevented the RP from making potential safety decisions. This situation was determined to be an Immediate Jeopardy (IJ), which began on 11/28/14. The facility's Administrator was notified of the IJ and Substandard Quality of Care (SQC) on 12/09/14. An Acceptable Allegation of Compliance was received on 12/11/14 in which the facility alleged the IJ was removed on 12/11/14. The State Survey Agency determined the IJ was removed on 12/12/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.10 (F157) was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the undated facility policy entitled, "Family Notification," revealed, "The family will be notified of any resident changes ie; (b. Health problems)." This policy further stated, "All significant family contact will be documented. This should include discussion of transfer, discharges, problem with care or roommate, significant changes in family support system, etc." Review for the facility policy dated, "08/14" entitled, "At A Glance Change in Resident Condition," directed staff to review the Advance Care Plan and contact the DCS (Director of Clinical Services, also known as the Director of Nursing) before contacting the PCP (Primary Care Provider). When contacting the PCP, staffs are instructed to communicate changes to the PCP for decision-making. Review of the incident report by the facility to the State Agency on 12/04/14, revealed Resident #1 left the facility without staff knowledge on 12/01/14 and was returned to the facility by Certified Nurse Aide (CNA) #1. Interview on 12/08/14 at 11:04 AM with CNA #1 at 11:04 AM, CNA #1 confirmed she found Resident #1 outside the facility on 12/01/14, ambulating down the street in front of her home. CNA #1 placed Resident #1 in her private car and returned him to the facility. On 12/08/14 at 11:39 AM, the distance from the facility to the location where Resident #1 was picked up by CNA #1 was measured to be three-tenths (.3) of a mile, and required Resident #1 to cross a busy street. Review of Resident #1's Nurses' Notes revealed on 11/28/14 at 12:45 AM, Licensed Practical Nurse (LPN) #1 wrote, "Resident was noted earlier at beginning of shift to be exhibiting exit seeking behavior. CNA brought resident back to the IC Wing. Resident stated, 'I was trying to get out of here' ". No documentation was found in Resident #1's record that the physician or responsible party was notified on 11/28/14 of these behaviors. During an interview with LPN #1 on 12/10/14 at 10:02 AM, LPN #1 confirmed CNA #4 brought Resident #1 back to the hall and informed LPN #1 of Resident #1 being at the front door of the facility. LPN #1 confirmed she did not contact the Unit Manager or any other facility staff regarding observations of the resident's exit seeking on 11/28/14. LPN #1 confirmed she had not seen Resident #1 exhibit exit seeking behavior prior to this; however, no assessment, evaluation, or monitoring was initiated on Resident #1. Interview with CNA #4 on 12/11/14 at 4:07 PM revealed CNA #4 confirmed observing Resident #1 on 11/28/14 walking around the facility and returned Resident #1 to unit where he resided. CNA #4 stated, "I told the nurse, when (LPN #1 name) came on, to keep an eye on him because he was rambling around there." During an interview with Resident #1's Responsible Party (RP) on 12/09/14 at 8:20 PM, the RP confirmed the first time she was contacted regarding Resident #1 attempting to leave the facility was after the resident eloped on 12/01/14. Interview with alternate Physician #1 on 12/11/14 at 3:25 PM revealed the Physician confirmed he was not contacted regarding behavior of exit seeking on 11/28/14. The Primary Physician was out of town and unavailable. Physician #1 stated he was contacted on 12/01/14 regarding Resident #1's elopement from the facility and was familiar with Resident #1 due to previously seeing him in the hospital prior to admission to the facility on [DATE]. LPN #1's failure to contact a physician or Resident #1's responsible party on 11/28/14 resulted in the lack of oversight by the Director of Nursing, the Administrator, a physician, and input from the RP which also resulted in no interventions implementation to ensure the protection and safety of Resident #1. Resident #1 eloped from the facility on 12/01/14. An interview with the Administrator and the Director of Nursing (DON) on 12/08/14 at 9:35 AM revealed both staff members denied knowledge of Resident #1 exhibiting any behaviors or being at an elopement risk prior to leaving the facility on 12/01/14, when Resident #1 left the facility unauthorized and without staff knowledge on 12/01/14 and was returned to the facility by Certified Nurse Aide (CNA) #1. Interview with Unit Manager, RN #1, on 12/08/14 at 12:09 PM, RN #1 confirmed CNA #2 contacted her around 12:30 PM on 12/01/14 and reported Resident #1 "trying to go out." RN #1 confirmed she attempted to contact the resident's physician to obtain an order for [REDACTED]. Interview with LPN #2 on 12/08/14 at 1:45 PM, LPN #2 confirmed Unit Manager, RN #1, notified her of Resident #1 attempting to leave at the front exit around 1:00 PM on 12/01/14. LPN #2 confirmed she continued to attempt to contact the physician to obtain an order for [REDACTED]. Review of Resident #1's nurses' notes revealed the facility attempted to contact physician on 12/01/14 concerning exit seeking behaviors; however, the facility did not attempt to contact with the Responsible Party of the change in status until Resident #1 eloped and staff returned him to the facility. During an additional interview with the Director of Nurses (DON) on 12/12/14 at 1:04 PM, the DON confirmed staff notified her of the 11/28/14 nurses' note documentation by LPN #1 during review of Resident #1's record following the elopement on 12/01/14. Observation and interview with Resident #1 on 12/08/14 at 10:15 AM, revealed Resident #1 stated he had been at the facility "three months or better". (Resident was admitted on [DATE] to the facility, which was a three days over a month at time of interview.) and was unable to recall the name of the facility, or the name of his physician. Resident #1 stated regarding 12/01/14 exit of the building, "I started walking and just went walking." The facility admitted Resident #1 on 11/05/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/14 revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognitive status. No wandering or changes in behavior were observed, and Resident #1 was assessed as ambulatory with independent ambulation. The facility submitted an acceptable credible Allegation of Compliance on 12/11/14 for the Immediate Jeopardy. Review of the facility's Allegation of compliance revealed the facility took the following actions to remove the Immediate Jeopardy. 1. On 12/01/2014 at approximately 3:45 p.m. CNA#1 called stating she was bringing Resident #1 back to the facility as she had picked him up in her neighborhood. CNA#3 notified the administrator Resident #1 was in parking lot with CNA#1. The administrator called the DON and Unit Nurse Manager of hall where resident resides to her office. The DON and Unit Nurse Manager of hall where resident resides went outside to assist with getting Resident #1 back into the building. 2. He was returned to the nurses' station of the hall where resident resides at approximately 4:00 PM. He was assessed with [REDACTED]. observation and care plan created to show elopement risk. RP and MD were notified at this time. 3. The alternate physician #1 responded to the call giving ok for wander guard and order was given to send to the local hospital on the morning of 12/02/2014. MD states that he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. On December 1, 2014, an audit for elopement risk was done on entire resident census of 130 residents to identify other residents that have the potential to be affected. This audit was performed by DON, ADON, and Unit Managers. Of the 130 residents assessed, 7 residents were identified including resident number #1 at risk for elopement. 7 out of 7 care plans were reviewed including Resident #1 who required a new care plan for elopement. No other updates to care plans were needed at this time. 5. On 12/01/2014, in-service of staff began at 4:30 PM and continued until 12/10/ 14 at 9:30 AM by the DON (Director of Nurses) and ADON (Assistant Director of Nurses) to educate all full time RN, LPN's, CNA's, Housekeeping, Laundry, Maintenance, Activities, Social, Therapy, Dietary, Human Resources, Central Supply and Administration. 165 employees were in serviced by 12/10/2014 at 9:30 AM. 5 PRN (as needed) employees were unable to be reached. Those employees were taken out of the payroll system, a certified letter mailed to them and they will not be allowed to return to work until they have been in serviced. New hires will be inserviced before they begin to work. In service includes Policy # N-1031 Guide to Elopement Risk Assessment which covers risk factors which may cause a resident to be at risk for elopement and Policy N -1030 Elopement Education which covers protocol for staff to follow in case of a missing resident. No staff will be allowed to return to work until in serviced. 6. There are no contracted nurses employed at this facility. 7. The education content included our new internal protocol which states that that all staff is responsible for monitoring our residents and ensuring where they are and they are safe. This includes all disciplines. If a resident is a potential for elopement, nursing must be notified so that the resident can be properly assessed for a wander guard. If a change is noticed in a resident such as increased confusion, exit seeking, etc., nursing must also be notified and the resident must be placed on 1 on 1 observation until a registered nurse can assess and determine the cause of the new behavior. An RN should also assess resident for wander guard and if warranted, place wander guard on resident immediately, if no RN in building, staff will notify DON immediately and resident will remain on 1 on 1 until that time. It was reiterated that if you notice a change in your resident such as exit seeking, notify nurse immediately. Do not leave resident unattended until that nurse has resident and RN is assessing them to determine what is going on. Resident must remain supervised until staff can determine cause or place wander guard on resident. Employees have been instructed on the elopement policies and new internal protocol which was initiated on 12/1/2014. Employees understand that failure to follow policy/protocol could result in the potential for neglect. No staff will be allowed to return to work until in serviced. 8. On 12/02/2014 all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. All 8 doors and alarms were working properly. 9. On 12/02/2014 elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. An emergency QA meeting was conducted to review this incident on 12/02/2014 3:00 PM to include the Medical Director, ED, DON, ADON, 2 CNA's (certified Nursing Assistants), Unit Managers, Social Worker, Maintenance and Receptionist. The topic discussed was the elopement and the resident's medical record was reviewed. The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. We reviewed audits of elopement risks and the in-services that were given to the staff. The committee will review this issue within 30 days. 11. On 12/02/2104 at approximately 2:00 PM, a phone call was placed to MSDH (Mississippi State Department of Health), message left on voicemail. Investigative report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM. 12. The facility alleges immediate jeopardy was removed on 12/11/2014. On 12/12/14, the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. Interview with the DON and Unit Nurse Manager revealed as soon as they were notified of Resident #1's elopement, they went outside to assist with getting Resident #1 back into the building. 2. The state surveyor validated the resident was assessed with [REDACTED]. It was further validated, that Resident #1's Responsible Party and the alternate attending Physician were notified at this time. 3. Interview with the alternate attending physician#1 validated the order giving approval for a wander guard and an order was given to send to the local hospital on the morning of 12/02/2014. The physician stated he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. A review of the facility's audit for elopement risk validated 130 residents were audited with 7 residents identified to be at risk for elopement. The care plans for the 7 residents at risk were reviewed and updated as needed. 5. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheets provided by the facility's provided by the Director of Nursing and the Assistant Director of Nursing validated all staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants,Housekeeping, Laundry, Maintenance, Activities, Social Services, Therapy, Dietary, Human Resources, Central Supply and Administration. The State Agency validated that new employees and employees that could not be reached for inservice were taken out of the payroll system. The SA validated certified letters were mailed to the prn employees and they will not be allowed to return to work until they have been in serviced. 6. Review of Time Sheets and the working schedule validated the facility has no contracted nurses employed at this facility. 7. Review of the in-service content and sign in sheets related to the facility's new internal protocol which states that that all staff were in-serviced on responsibility for monitoring all residents and ensuring where they are and they are safe. This included all disciplines and all shifts. 8. Review of the Maintenance Directors records validated all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. The State Surveyor validated by observation of staff all 8 doors were functioning and the wander guard alarms were working. 9. A review of the Elopement Drill sign in sheets validated that elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. A review of the sign in sheet with content validated an emergency QA meeting was conducted on 12/2/14 at 2:00 PM which included the Medical Director, Administrator, DON, ADON, 2 CNAs, Unit Managers, Social Worker, Maintenance Director and the Receptionist. The topics discussed were the elopement and the new internal protocol The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. The Quality Assurance committee reviewed audits of elopement risks and the in-services that were in progress. 11. An interview with the facility Administrator validated the elopement had been reported to the state department of health on 12/02/2104 at approximately 2:00 PM, Phone call left on voicemail. The Investigative Report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM.

Based on record review, policy review, interview, and observation, the facility failed to provide adequate supervision to prevent a resident from leaving the facility without authorization and without the benefit of staff supervision, Resident #1. This was for one (1) of six (6) residents sampled for wandering. Resident #1 left the facility alone and ambulated three-tenths (.3) of a mile across a busy street. The staff was unaware that the resident was missing from the facility. The resident noticed by off duty Certified Nurse Aide (CNA) #1 and was returned to the facility. The facility's failure to provide supervision to prevent the resident from being outside the facility unsupervised and failure to implement its policy and procedures and develop a plan of action to prevent a recurrence was likely to cause serious injury, harm, impairment or death to Resident #1 and other residents assessed for wandering. The facility was notified on 12/09/14 of the Immediate Jeopardy at 42 CFR 483.25 (H) (2) Supervision (F323). An acceptable Allegation of Compliance (AOC) was received on 12/11/14 in which the facility alleged removal of the IJ on 12/11/14. The State Survey Agency determined the Immediate Jeopardy was removed on 12/12/14 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (H)(2) F323 was lowered to the scope and severity of a "D" while the facility develops and implements a plan of correction and monitors the effectiveness of the systematic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the undated facility policy entitled, "Elopement Education", (N-1030) stated, "Elopement is unsupervised or unassisted flight from the facility." This policy defined elopement risk factors to be: History of wandering and/or elopement, new admit with adjustment difficulties or desire to return home, acute or chronic confusion/disorientation, restlessness, irritability, anxiety, and Dementia. Review of the undated facility policy entitled, "Guide to Elopement Risk Assessment" (N-1031) did not provide instructions for staff regarding resident's exhibiting high risk for elopement behavior or the need for supervision to ensure resident's safety or elopement. The facility failed to assess and implement measures for increased supervision to ensure the safety of Resident #1 on 11/28/14, following staff observing Resident #1 roaming aimlessly about the facility and making statments of leaving. This lead to Resident #1 exiting the facility on 12/01/14 without staff knowledge, ambulating three tenths (.3) miles from the facility and being brought back to the facility by off duty CNA # 1. Review of the facility report made to the State Agency on 12/04/14, revealed Resident #1 left the facility without staff knowledge on 12/01/14 and was returned to the facility by Certified Nurse Aide (CNA) #1 about 3:45 PM. The report stated Resident #1 was last seen by the Unit Manager, (Registered Nurse (RN) #1) in the building about 3:35 PM. During an interview with the Administrator and the Director of Nursing (DON) on 12/08/14 at 9:35 AM, both confirmed Resident #1 left the facility unauthorized and without staff knowledge on 12/01/14. Both staff members denied knowledge of Resident #1 exhibiting exit seeking behaviors or being at an elopement risk prior to leaving the facility on 12/01/14. Interview with Resident #1's Responsible Party (RP) on 12/09/14 at 8:20 PM, RP confirmed Resident #1 required assistance with making decisions. The RP confirmed staff contacted her on 12/2/14, (after they had attempted to contact her on 12/01/14 unsuccessfully) and informed her that Resident #1 had left the building without their knowledge. Review of Resident #1's record revealed, Licensed Practical Nurse (LPN) #1 documented on 11/28/14 at 12:45 AM, "Resident was noted earlier at beginning of shift to be exhibiting exit seeking behavior. CNA brought resident back to the (name of Resident #1's unit). Resident stated, 'I was trying to get out of here' ". Interview with CNA #4 on 12/11/14 at 4:07 PM, CNA #4 confirmed he brought Resident #1 back to resident's unit on 11/28/14 after observing him walking around the facility. CNA #4 stated, "I told the nurse, when (LPN #1 name) came on, to keep an eye on him because he was rambling around there". Interview with LPN #1 on 12/10/14 at 10:02 AM, LPN #1 confirmed CNA #4 brought Resident #1 back to the hall and informed her of resident being at the front door of the facility. LPN #1 confirmed she did not inform unit manager or any other staff regarding observations of Resident exit seeking on 11/28/14 and did not complete an assessment or initiate monitoring of Resident #1 at that time to evaluate his condition. On 12/08/14 at 11:04 AM, during an interview with Certified Nurse Aide (CNA) #1, CNA #1 confirmed she was off duty, at home on 12/01/14, when she saw "a man walking through the trailer park". CNA #1 continued, "He looked tired, and he was going walking. I got my car keys and came, and when I got up to him he was trying to figure out which direction he wanted to go in". CNA #1 revealed Resident #1 informed her he was going to his girlfriend's house. CNA #1 then stated she drove him to the facility, and CNA #3 was at the front door to the facility. (CNA #1 stated it was about 4:01 PM.) CNA #3 informed the administrator of CNA #1 having Resident #1 in her vehicle. CNA #1 confirmed the Administrator paged the Director of Nursing and Unit Manager (RN#1), and they assisted Resident #1 back into the facility. On 12/08/14 at 11:39 AM, with the assistance of CNA #1, the route Resident #1 walked from the facility was observed by the surveyor. The distance from the facility to where Resident #1 was picked up by CNA #1 measured three-tenths (.3) of a mile, and required Resident #1 to cross a busy street directly in front of the facility before he entered the residential area where he was found. The CNA #1 intervened as the resident approached a stop sign intersecting another busy street. CNA #1's home, where she was sitting when she identified Resident #1, was across the street from this stop sign. The State Surveyor observed 13 cars passing in both directions on the street in front of the facility and counted three (3) cars passing in all directions while at stop sign where CNA #1 observed Resident #1. Review of statement submitted by CNA #1 on 12/01/14 to the facility Administrator, stated, "I was sitting on my steps outside when I saw a man walking through the trailer park, he was acting as if he was lost, cause he was walking and didn't know which direction he wanted to go in! Cars was approaching but he was still walking in the middle of the road on (name of intersecting streets at stop sign)." CNA #1's statement continued,"got in my car, (and) went to where he was walking at, but it was (two) other vehicles ahead of me, that he was walking in front of, they offered him a ride (and) he was attempting to get in it, but I got out of my vehicle and told them I would take them where he wants to go, and he didn't hesitate, he knew my face." Observation and interview with Resident #1 on 12/08/14 at 10:15 AM, revealed Resident #1 was disoriented to place and time and did not know the name of his attending physician. Resident #1 stated he had been at the facility for "three (3) months or better"; however, the facility admitted Resident #1 approximately one month earlier on 11/05/14. Resident #1 stated he left the facility, after he saw "people standing up talking to each other, (at the front door). Resident #1 stated "I just walked on through. I won't do that no more; I think about myself what could have happened". Resident #1 revealed on the day of the elopement, he was going to see a friend at (name for community) and revealed it was about "half a mile" from the facility. Resident #1 seated on his bed in his room with a wander guard on his ankle. On 12/09/14 at 1:20 PM, LPN #2 confirmed the residential area to the left of the nursing home was called (name of community). LPN #2 confirmed the resident went in the opposite direction of the community when he left the facility unsupervised on 12/01/14. Interview with CNA #2 on 12/08/14 at 1:24 PM, CNA #2 revealed on 12/1/14 between 12:15 PM and 12:30 PM, CNA #2 stopped Resident #1 from exiting front door of facility. CNA #2 recalled Resident #1 stated, "I'm going out". CNA #2 stated she informed Resident #1 he would have to be checked out of the facility by his family, Resident #1 stated, "Okay" and began ambulating towards hall where he resided. CNA #2 confirmed contacting the Social Service Director (SSD) and the Unit Manager (RN #1), the Unit Manager stated she would contact the doctor to get an order for [REDACTED].#2 confirmed just prior to 3:00 PM (unable to recall exact time) on 12/01/14, she observed Resident #1 again at the front exit door of the facility attempting to exit. CNA #2 stated she redirected Resident #1 but no staff member was contacted. Interview with RN #1 on 12/08/14 at 12:49 AM, RN #1 confirmed CNA #2 contacted her around 12:30 PM on 12/01/14 and reported Resident #1 "trying to go out". RN #1 confirmed she attempted to contact the resident's physician to obtain an order for [REDACTED].#2 to continue to try to reach the physician. RN #1 confirmed statement she provided to the administrator, stating she saw Resident #1 ambulating down an alternate hall at 3:30 PM on 12/01/14. RN #1 confirmed no wander guard was placed, no assessment was completed and no changes in supervision for Resident #1 was performed prior to Resident #1 leaving the facility without staff supervision. RN #1 confirmed Resident #1 was assessed as an elopement risk with a wander guard placed upon CNA #1 returning him to the facility on [DATE]. On 12/09/14 at 8:40 AM during an interview with the DON, the DON stated she was unaware of staff observing Resident #1 attempting to leave until after he was returned to the facility from leaving without staff supervision or knowledge. DON stated, "I think they (nurses) didn't understand the seriousness of him being at the door, thought it was just (Resident #1's name)". During an interview with Speech Therapist (ST) on 12/8/14 at 3:30 PM, ST confirmed treating Resident #1 on 12/01/14. ST confirmed Resident #1 was showing an increase in confusion on 12/01/14, and informed her that he was going home and was going to walk there. ST confirmed reporting this to her Program Manager (Licensed Physical Therapy Assistant) (LPTA #1) of this change in Resident ' s behavior and he informed the nursing staff for Resident #1. During an interview with LPTA #1 on 12/08/14 at 3:25 PM, LPTA #1 confirmed reporting Resident #1's comments to ST regarding going home, to the Unit Manager, RN #1 around 2:30 PM on 12/01/14. Interview with LPN #2 on 12/08/14 at 1:45 PM, LPN #2 confirmed Unit Manager, RN #1 informed her of Resident #1 attempting to leave around 1:00 PM on 12/01/14. LPN #2 revealed Resident #1 had returned to the couch at the nurses' station and said a friend was having a get together at which time she and RN #1 "reinforced with him" he would need to have someone sign him out. LPN #2 confirmed no further communication or assessment was conducted as to Resident #1's behavior, and that she continued to attempt to contact the physician to obtain an order for [REDACTED].#2 stated she was unaware if Resident #1 attempted to exit the building unsuccessful any more on 12/01/14 prior to leaving the building without supervision. Interview with Registered Nurse (RN) #2 on 12/08/14 at 5:28 PM, RN #2 confirmed working the 3:00 PM to 11:00 PM shift on 12/01/14. RN #2 confirmed LPN #2 informed her Resident #1 had been "trying to get out all day and she told me they were going to get him a wander guard. She said she had just looked in on him and he was in his room". RN #2 confirmed she was never instructed for Resident #1 to be on any monitoring or increased supervision, and she did not see Resident #1 until he was returned to the unit after being returned to the facility by CNA #1 on 12/01/14. No changes were made in the supervision of Resident #1 on 12/01/14 prior to his leaving the facility unsupervised on 12/01/14. Interview with the DON on 12/12/14 at 1:04 PM, the DON confirmed not being made aware of 11/28/14 documentation of LPN #1 until after Resident #1 left the facility unsupervised on 12/01/14. The DON stated, "She should have asked more questions. She should have placed him on one to one (monitoring) and called me". Interview with the alternate Physician #1, who was contacted on 12/01/14 regarding Resident #1's elopement from the facility, revealed he ordered for Resident #1 to be admitted to the hospital on [DATE] for observation and assessment and to rule out any medical cause for increased confusion. Physician #1 confirmed at the end of hospital stay on 12/04/14, he felt Resident #1 had increased confusion due to worsening dementia. Physician #1 confirmed he was not contacted regarding resident ' s exit seeking behavior on 11/28/14. Review of the signed job description for "Unit Manager", signed by RN #1 on 05/29/14, revealed the following duties under "Nursing Care Functions", Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request. Authorize the use of restraints when necessary and in accordance with our established policies and procedures." The facility admitted Resident #1 on 11/05/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/14 revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognitive status. No wandering or changes in behavior were observed, and Resident #1 was assessed as ambulatory with independent ambulation. The facility submitted an acceptable credible Allegation of Compliance on 12/11/14 for the Immediate Jeopardy. Review of the facility's Allegation of compliance revealed the facility took the following actions to remove the Immediate Jeopardy. 1. On 12/01/2014 at approximately 3:45 p.m. CNA#1 called stating she was bringing Resident #1 back to the facility as she had picked him up in her neighborhood. CNA#3 notified the administrator Resident #1 was in parking lot with CNA#1. The administrator called the DON and Unit Nurse Manager of hall where resident resides to her office. The DON and Unit Nurse Manager of hall where resident resides went outside to assist with getting Resident #1 back into the building. 2. He was returned to the nurses' station of the hall where resident resides at approximately 4:00 PM. He was assessed with [REDACTED]. observation and care plan created to show elopement risk. RP and MD were notified at this time. 3. The alternate physician #1 responded to the call giving ok for wander guard and order was given to send to the local hospital on the morning of 12/02/2014. MD states that he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. On December 1, 2014, an audit for elopement risk was done on entire resident census of 130 residents to identify other residents that have the potential to be affected. This audit was performed by DON, ADON, and Unit Managers. Of the 130 residents assessed, 7 residents were identified including resident number #1 at risk for elopement. 7 out of 7 care plans were reviewed including Resident #1 who required a new care plan for elopement. No other updates to care plans were needed at this time. 5. On 12/01/2014, in-service of staff began at 4:30 PM and continued until 12/10/ 14 at 9:30 AM by the DON (Director of Nurses) and ADON (Assistant Director of Nurses) to educate all full time RN, LPN's, CNA's, Housekeeping, Laundry, Maintenance, Activities, Social, Therapy, Dietary, Human Resources, Central Supply and Administration. 165 employees were in serviced by 12/10/2014 at 9:30 AM. 5 PRN (as needed) employees were unable to be reached. Those employees were taken out of the payroll system, a certified letter mailed to them and they will not be allowed to return to work until they have been in serviced. New hires will be inserviced before they begin to work. In service includes Policy # N-1031 Guide to Elopement Risk Assessment which covers risk factors which may cause a resident to be at risk for elopement and Policy N -1030 Elopement Education which covers protocol for staff to follow in case of a missing resident. No staff will be allowed to return to work until in serviced. 6. There are no contracted nurses employed at this facility. 7. The education content included our new internal protocol which states that that all staff is responsible for monitoring our residents and ensuring where they are and they are safe. This includes all disciplines. If a resident is a potential for elopement, nursing must be notified so that the resident can be properly assessed for a wander guard. If a change is noticed in a resident such as increased confusion, exit seeking, etc., nursing must also be notified and the resident must be placed on 1 on 1 observation until a registered nurse can assess and determine the cause of the new behavior. An RN should also assess resident for wander guard and if warranted, place wander guard on resident immediately, if no RN in building, staff will notify DON immediately and resident will remain on 1 on 1 until that time. It was reiterated that if you notice a change in your resident such as exit seeking, notify nurse immediately. Do not leave resident unattended until that nurse has resident and RN is assessing them to determine what is going on. Resident must remain supervised until staff can determine cause or place wander guard on resident. Employees have been instructed on the elopement policies and new internal protocol which was initiated on 12/1/2014. Employees understand that failure to follow policy/protocol could result in the potential for neglect. No staff will be allowed to return to work until in serviced. 8. On 12/02/2014 all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. All 8 doors and alarms were working properly. 9. On 12/02/2014 elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. An emergency QA meeting was conducted to review this incident on 12/02/2014 3:00 PM to include the Medical Director, ED, DON, ADON, 2 CNA's (certified Nursing Assistants), Unit Managers, Social Worker, Maintenance and Receptionist. The topic discussed was the elopement and the resident's medical record was reviewed. The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. We reviewed audits of elopement risks and the in-services that were given to the staff. The committee will review this issue within 30 days. 11. On 12/02/2104 at approximately 2:00 PM, a phone call was placed to MSDH (Mississippi State Department of Health), message left on voicemail. Investigative report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM. 12. The facility alleges immediate jeopardy was removed on 12/11/2014. On 12/12/14, the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. Interview with the DON and Unit Nurse Manager revealed as soon as they were notified of Resident #1's elopement, they went outside to assist with getting Resident #1 back into the building. 2. The state surveyor validated the resident was assessed with [REDACTED]. It was further validated, that Resident #1's Responsible Party and the alternate attending Physician were notified at this time. 3. Interview with the alternate attending physician#1 validated the order giving approval for a wander guard and an order was given to send to the local hospital on the morning of 12/02/2014. The physician stated he wanted to evaluate the patient but did not feel that it was an emergent situation so he made the decision to admit him on 12/02/2014. 4. A review of the facility's audit for elopement risk validated 130 residents were audited with 7 residents identified to be at risk for elopement. The care plans for the 7 residents at risk were reviewed and updated as needed. 5. Staff interviews across all shifts and all disciplines and review of the in-service content and sign in sheets provided by the facility's provided by the Director of Nursing and the Assistant Director of Nursing validated all staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants,Housekeeping, Laundry, Maintenance, Activities, Social Services, Therapy, Dietary, Human Resources, Central Supply and Administration. The State Agency validated that new employees and employees that could not be reached for inservice were taken out of the payroll system. The SA validated certified letters were mailed to the prn employees and they will not be allowed to return to work until they have been in serviced. 6. Review of Time Sheets and the working schedule validated the facility has no contracted nurses employed at this facility. 7. Review of the in-service content and sign in sheets related to the facility's new internal protocol which states that that all staff were in-serviced on responsibility for monitoring all residents and ensuring where they are and they are safe. This included all disciplines and all shifts. 8. Review of the Maintenance Directors records validated all 8 exit door codes were changed by maintenance director and all 8 exit door alarms were checked for proper function of wander guards by CNA #2. The State Surveyor validated by observation of staff all 8 doors were functioning and the wander guard alarms were working. 9. A review of the Elopement Drill sign in sheets validated that elopement drills were conducted on each of the 3 shifts by the maintenance director. The drills were held at 6:00 AM, 10:20 AM and 3:30 PM and included 49 staff members that were working on those 3 shifts. 10. A review of the sign in sheet with content validated an emergency QA meeting was conducted on 12/2/14 at 2:00 PM which included the Medical Director, Administrator, DON, ADON, 2 CNAs, Unit Managers, Social Worker, Maintenance Director and the Receptionist. The topics discussed were the elopement and the new internal protocol The new Protocol which was initiated on 12/1/2014 was discussed, this protocol includes educating staff on what to do if a change is noted in your resident, notifying nursing staff of any wandering behavior and when to place residents on 1 on 1 observation. The Quality Assurance committee reviewed audits of elopement risks and the in-services that were in progress. 11. An interview with the facility Administrator validated the elopement had been reported to the state department of health on 12/02/2104 at approximately 2:00 PM, Phone call left on voicemail. The Investigative Report was faxed to MSDH on 12/03/2014 at approximately 4:30 PM.

CI MS # Based on interview, facility policy review, and record review, the facility failed to ensure residents personal property in the form of money was protected for 8 of 8 sampled residents (#1, #2, #3, #4, #5, #6, #7, and #8), from a total of 13, to include 18 of 18 Unsampled residents (Unsampled Residents #A, #B, #C, #D, #E, #F, #G, #H, #I, #J, #K, #L, #M, #N, #O, #P, #Q and #R). This resulted in Immediate Jeopardy and Substandard Quality of Care for the misappropriation of personal finances between [DATE] - [DATE], to the sum of $1580.98 that involved 26 residents, with the likelihood of misappropriation and associated mental anguish. Findings include: During an entrance conference [DATE] at 9:15 a.m., the Executive Director (ED) #1 said the facility found money missing from resident trust fund accounts. During an interview [DATE] at 10:20 a.m., the facility's Regional Director of Business Office Services (RDBOS) #1 said she was called to the facility and began an audit [DATE] when Business Office Manager (BOM) #1 identified missing cash from the room and board payment (operating) accounts. RDBOS #1 said her audit for dates between [DATE] and [DATE], revealed $4056.13 was missing from cash receipted for room and boards. RDBOS #1 said a total of 8 cash payments remained missing from the facility's operating account and that Receptionist (RC) #1 had signed for 7 of those or a total of $3545.13. RDBOS #1 said the first audit raised concerns with cash transactions conducted by RC #1 who was also responsible for all Resident Trust Fund Accounts and subsequently a second audit was conducted. RDBOS #1 said 26 Resident Trust Fund Accounts from a total of 126 revealed missing funds that totaled $1580.98. Resident #1 According to the face sheet dated [DATE], Resident #1 was a [AGE] year old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #1 remained at the facility. The Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had no cognitive impairments and she relied on minimally one staff member to assist her with all activities of daily living. Review of two "patient fund cash receipt(s)" from the facility revealed Receptionist #1 (RC) and Medical Records #1 (MR) were entrusted to deposit cash into Resident #1's personal trust fund account on: 1) [DATE] in the amount of $20.00; and 2) [DATE] in the amount of $20.00. An open "active" trust fund balance record for Resident #1 dated from when the account was opened [DATE] revealed these two cash deposits were never posted to the residents account. Resident #2 According to Resident #2's face sheet dated [DATE], Resident #2 was a [AGE] year old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #2 remained at the facility. The MDS dated [DATE] documented Resident #2 had severe cognitive impairments and she relied on minimally one staff member to assist her with all activities of daily living. Review of a "patient fund cash receipt" from the facility revealed RC#1 was entrusted to deposit cash into Resident #2's personal trust fund account on [DATE] in the amount of $25.00. An open "active" trust fund balance record for Resident #2 dated from when the account was opened [DATE] revealed the cash deposit was never posted to the residents account. Resident #3 Record review of the face sheet dated [DATE] revealed Resident #3 was a [AGE] year old female admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Resident #3 remained at the facility. The MDS dated [DATE] documented Resident #3 had severe cognitive impairments and she relied on minimally one staff member to assist her with all activities of daily living. Physician orders [REDACTED]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #3's personal trust fund account on [DATE] in the amount of $13.25. An open "active" trust fund balance record for Resident #3 dated [DATE] revealed the cash deposit was never posted to the residents account. Resident #4 According to the face sheet dated [DATE], Resident #4 was a [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #4 remained at the facility. The MDS dated [DATE] documented Resident #4 had no cognitive impairments and he relied on minimally one staff member to assist him with all activities of daily living. Review of "patient fund cash receipt(s)" from the facility revealed RC#1 was entrusted to deposit cash into Resident #4's personal trust fund account on: 1) [DATE] in the amount of $6.50; 2) [DATE] in the amount of $14.00; 3) [DATE] in the amount of $10.00; 4) [DATE] in the amount of $5.00; and 5) [DATE] in the amount of $5.00. An open "active" trust fund balance record for Resident #4 dated from when the account was opened [DATE] revealed these cash deposits were never posted to the residents account. Resident #5 According to the closed records face sheet dated [DATE], Resident #5 was a [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #5 died at the facility on [DATE]. The MDS dated [DATE] documented Resident #5 had cognitive impairments and he relied on minimally one staff member to assist him with all activities of daily living. Review of a "patient fund cash receipt" from the facility revealed RC#1 was entrusted to deposit cash into Resident #5's personal trust fund account on [DATE] in the amount of $400.00. A closed trust fund balance record for Resident #5, dated between the accounts open date of [DATE] and the close date of [DATE] revealed the cash deposit was never posted to the residents account. Resident #6 According to the closed records face sheet dated [DATE], Resident #6 was a [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #6 was discharged home [DATE]. The MDS dated [DATE] documented Resident #6 had no cognitive impairments and he relied on minimally one staff member to assist him with all activities of daily living. Review of a "patient fund cash receipt" from the facility revealed RC#1 was entrusted to deposit cash into Resident #6's personal trust fund account on [DATE] in the amount of $200.00. A closed trust fund balance record for Resident #6, dated between the accounts open date of [DATE] and the close date of [DATE] revealed the cash deposit was never posted to the residents account. Resident #7 According to the face sheet dated [DATE], Resident #7 was a [AGE] year old female readmitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #7 remained at the facility. The MDS dated [DATE] documented Resident #7 had no cognitive impairments and she relied on minimally one staff member to assist him with all activities of daily living. Review of "patient fund cash receipt(s)" from the facility revealed Receptionist #1, prior Executive Director #1, and prior Social Worker #1, (who both due to personal advancement were no longer employed by the facility), were entrusted to deposit cash into Resident #7's personal trust fund account on: 1) [DATE] in the amount of $20.00; 2) [DATE] in the amount of $15.00; 3) [DATE] in the amount of $20.00; 4) [DATE] in the amount of $37.00; 5) [DATE] in the amount of $10.00; and 6) [DATE] in the amount of $20.00. An open "active" trust fund balance record for Resident #7 dated from when her initial account was opened [DATE] revealed these cash deposits were never posted to the residents account. Resident #8 According to the face sheet dated [DATE], Resident #8 was a [AGE] year old male readmitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #8 died at the facility on [DATE]. The MDS dated [DATE] documented Resident #8 had some cognitive impairments and he relied on minimally one staff member to assist him with all activities of daily living. Review of a "patient fund cash receipt" from the facility revealed RC#1 was entrusted to deposit cash into Resident #8's personal trust fund account on [DATE] in the amount of $220.00. A comprehensive record review failed to provide any documented evidence to suggest a trust fund account was ever opened for Resident #8. Unsampled Resident #A Unsampled Resident #A was an [AGE] year old female admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #A's personal trust fund account on [DATE] in the amount of $20.00. An open "active" trust fund balance record for Unsampled Resident #A dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #B Unsampled Resident #B was a [AGE] year old female admitted to the facility [DATE] and was discharged home on [DATE]. Review of "patient fund cash receipt(s)" from the facility revealed RC #1 was entrusted to deposit cash into Resident #B's personal trust fund account on: 1) ,[DATE] in the amount of 20.00; 2) [DATE] in the amount of $20.00; and 3) [DATE] in the amount of $20.00. An open "active" trust fund balance record for Unsampled Resident #B dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #C Unsampled Resident #C was an [AGE] year old female readmitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted by the responsible party to deposit cash into Resident #C's personal trust fund account on [DATE] in the amount of $10.00. An open "active" trust fund balance record for Resident #C dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #D Unsampled Resident #D was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #D's personal trust fund account on [DATE] in the amount of $20.00. An open "active" trust fund balance record for Unsampled Resident #D dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #E Unsampled Resident #E was a [AGE] year old male admitted to the facility [DATE] and was discharged home on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Unsampled Resident #E's personal trust fund account on [DATE] in the amount of $20.00. An open "active" trust fund balance record for Unsampled Resident #E dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #F Unsampled Resident #F was a [AGE] year old male admitted to the facility [DATE] and readmitted on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Unsampled Resident #F's personal trust fund account on [DATE] in the amount of $12.50. An open "active" trust fund balance record for Unsampled Resident #F dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #G Unsampled Resident #G was an [AGE] year old male admitted to the facility [DATE] and died at the facility on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Unsampled Resident #G's personal trust fund account on: 1) [DATE] in the amount of 20.00; 2) [DATE] in the amount of $40.00; and 3) [DATE] in the amount of $40.00. An open "active" trust fund balance record for Unsampled Resident #G dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #H Unsampled Resident #H was a [AGE] year old female admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #H's personal trust fund account on [DATE] in the amount of $50.33. An open "active" trust fund balance record for Unsampled Resident #D dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #I Unsampled Resident #I was a [AGE] year old female admitted to the facility [DATE] and was discharged home on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #I's personal trust fund account on: 1) [DATE] in the amount of 20.00; and 2) [DATE] in the amount of #50.00. An open "active" trust fund balance record for Unsampled Resident #I dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the resident's account. Unsampled Resident #J Unsampled Resident #J was an [AGE] year old female admitted to the facility [DATE] and was discharged home on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #J's personal trust fund account on [DATE] in the amount of $60.00. An open "active" trust fund balance record for Resident #J dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #K Unsampled Resident #K was an [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 and Business Office Manager #1 (BOM) were entrusted to deposit cash into Unsampled Resident #K's personal trust fund account on: 1) [DATE] in the amount of $30.00; and 2) [DATE] in the amount of $4.00. An open "active" trust fund balance record for Unsampled Resident #K dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #L Unsampled Resident #L was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC#1 was entrusted to deposit cash into Unsampled Resident #L's personal trust fund account on: 1) [DATE] in the amount of $1.92; and 2) [DATE] in the amount of $19.00. However, on an unknown date, at an unknown time, the carbon copy of the second receipt was altered to signify only $9.00. An open "active" trust fund balance record for Unsampled Resident #L dated from when her initial account was opened [DATE] revealed the only $9.00 of the $20.92 had been posted to the residents account. Unsampled Resident #M Unsampled Resident #M was a [AGE] year old female admitted to the facility [DATE] and readmitted on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Unsampled Resident #M's personal trust fund account on [DATE] in the amount of $22.73. An open "active" trust fund balance record for Unsampled Resident #M dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #N Unsampled Resident #N was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #N's personal trust fund account on [DATE] in the amount of $2.00. An open "active" trust fund balance record for Unsampled Resident #N dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #O Unsampled Resident #O was an [AGE] year old female admitted to the facility [DATE] and died at the facility on [DATE]. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #O's personal trust fund account on [DATE] in the amount of $0.25. A comprehensive review of facility records failed to reveal a trust fund account was ever opened for Unsampled Resident #O. Unsampled Resident #P Unsampled Resident #P was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Unsampled Resident #P's personal trust fund account on [DATE] in the amount of $7.00. An open "active" trust fund balance record for Unsampled Resident #P dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #Q Unsampled Resident #Q was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of an undated "patient fund cash receipt" from the facility revealed SW #1 was entrusted to deposit cash into Unsampled Resident #Q's personal trust fund in the amount of $11.00. An open "active" trust fund balance record for Unsampled Resident #Q dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. Unsampled Resident #R Unsampled Resident #R was a [AGE] year old female admitted to the facility [DATE] and remained at the facility. Review of a "patient fund cash receipt" from the facility revealed RC #1 was entrusted to deposit cash into Resident #R's personal trust fund account on [DATE] in the amount of $8.50. An open "active" trust fund balance record for Unsampled Resident #R dated from when her initial account was opened [DATE] revealed the cash deposit was never posted to the residents account. A report from local police department dated [DATE] revealed an officer had responded to the facility for a felony offense/incident of "embezzlement." Interview on [DATE] at 2:30 p.m. with the Regional Director of Business Services #1 said the facility practice prior to [DATE] allowed Receptionist (RC) #1 to handle all resident trust fund accounts including receipt, debit, credit, and audit. Regional Director of Business Services #1 said division of these duties was required in the facility policy to prevent misappropriation of resident funds. When asked if the policy was enforced after the facility identified the misappropriation on [DATE], Regional Director of Business Services #1 said no. Regional Director of Business Services #1 said since RC #1 was hired in ,[DATE], her work with resident trust funds had never been audited by the facility. She simply supplied management with monthly reports that went unchecked. Interview on [DATE] at 11:00 a.m. with the Business Office Manager (BOM) #1 said the facility's policy for "Cash Receipts" was not currently being followed due to short staffing. BOM #1 said the facility's policy precluded her from receipting money and preparing deposits. However, she said that she currently receipted, deposited, and even audited all cash transaction. Interview on [DATE] at 12:00 p.m. with Medical Records (MR) #1 said when she received cash for residents at the facility she always generated a receipt, provided the original copy to the payer, the yellow copy was placed with the money, and pink triplicate was left in the receipt book. MR #1 said she always placed the funds in the cash box after the transaction was completed. Interview on [DATE] at 2:00 p.m. with the Social Worker (SW) #1 said when she received cash for residents at the facility she always generated a receipt, provided the original copy to the payer, the yellow copy was placed with the money, and left the pink triplicate was left in the receipt book. SW #1 said she either placed the funds in the cash box, or handed them to RC #1 when she returned from break. Receptionist (RC) #1 said during an interview on [DATE] at 1:30 p.m., that she was responsible for the Resident Fund Management System. RC #1 said she worked full time and always had access to the facility's cash box. RC #1 said the cash box held unposted checks with the duplicate receipt, until the BOM #1 randomly retrieved them Monday through Friday. RC #1 said the cash box also held cash for the resident trust funds accounts and operations until she had time to leave the facility unattended with the cash, drive to the Post Office, and exchange the cash for a money order. RC #1 said when she received cash for either account a receipt was generated for the exact amount and provided to the payer. RC #1 said in her absence other staff members received the funds and placed them in the cash box with the duplicate receipt until she returned. On [DATE] at 1:30 p.m. during the interview, RC #1 reviewed 41 cash receipts unposted to resident trust fund accounts and said her signature indicated she received the documented funds. Without any provocation, RC #1 then looked at the stack of resident trust fund accounts with the unposted receipts, and said "I can explain the missing money." RC #1 never explained how she knew money was missing from each of the accounts in the stack. She stated the missing money had all been given back to the resident and/or their responsible party before it was posted to their accounts. Despite this claim, RC #1 was unable to provide any documented evidence to suggest the money had been returned. During a review of facility staffing, it was revealed that RC #1 either worked the same day, or the following day during the time when unposted money had been received by other staff. Interview on [DATE] at 6:30 p.m. with the Executive Director #1 revealed she was new to the facility but expected a problem because the cash box key was left unsecured and too many hands touched the money. The Administrator was informed on [DATE] at 3:30 p.m., of the immediate jeopardy and substandard quality of care identified [DATE], that began on [DATE] when the facility failed to prevent misappropriation of resident trust fund accounts resulting in the likelihood of misappropriation and associated mental anguish. The facility submitted a credible Allegation of Compliance (AoC) on [DATE] at 2:15 p.m. as followed: "On [DATE] at 4:30 p.m., BOM, identified a financial discrepancy and reported it to the Executive Director. The discrepancy was for 2 cash receipts signed by receptionist #1 dated [DATE] for 443.13 and [DATE] for $702.00. These were never posted to the residents Room & Board (Operations) Account. RDBOS (Regional Director of Business Services) was notified on [DATE] at 7:50 a.m. by BOM. RDBOS arrived at the facility [DATE] around 10:00 a.m. and began an operating account audits. RDBOS notified, Regional Vice President of Operations and District Business Office Services that discrepancies in operating accounts had been identified. Due to the discrepancies, found an audit of Resident Trust Fund Accounts with cash receipts began [DATE] at 9:30 a.m., by the RDBOS. The audit was completed on [DATE] at 6:00 p.m. 26 of 126 residents trust fund accounts with cash deposits had discrepancies. On [DATE] a request was made to Consulate Management Services for the 26 resident trust fund accounts to be credited for any accounting discrepancy for total amount of $1580.98. The results of the audit were as follows: Resident #1: On [DATE], $20.00 was receipted by Receptionist #1 but not posted to the resident's trust account. On [DATE], $20.00 was receipted by MR but not posted to the resident's account. On [DATE], $40.00 was credited to the resident's trust fund account. The Responsible Party was notified of the discrepancy on [DATE]. Resident #2: On [DATE], $25.00 receipted by receptionist #1, but was not posted to the resident's trust account. On [DATE] $25.00 was credited to the trust account. The RP was notified of the discrepancy on [DATE]. Resident #3: On ,[DATE], $13.25 was receipted by receptionist #1, but was not posted to the resident's trust account. On [DATE], $13.25 was credited to the trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #4: On [DATE], $6.50 was receipted by Receptionist #1 but not posted to the resident's trust account: On [DATE], in the amount of $14.00 was receipted by receptionist #1 but not posted to the resident's trust account. On [DATE], $5.00 receipted by receptionist #1 but was not posted to the resident's trust account; on [DATE], $10.00 receipted by Receptionist #1 but was not posted to the resident's trust account; on [DATE], $5.00 receipted by receptionist #1 but was not posted to the resident's trust account. On [DATE], $40.50 was credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #5: On [DATE], $400.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], a check was mailed to resident's RP. The RP was notified of the discrepancy on [DATE]. Resident #6: On [DATE], $200.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident #7: On [DATE], $20.00 cash was receipted by the former Executive Director but was not posted to the resident's trust account: On [DATE], $15.00 cash was receipted by the former admission coordinator but was not posted to the resident's trust account: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $37.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $10.00 cash was receipted by the medical records clerk but was not posted to the resident's trust account: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $122.00 credited to the residents trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #8: On [DATE], $220.00 cash was receipted by receptionist #1 but was not posted to the resident's trust account: On [DATE], funds were mailed to resident's RP. The RP was notified of the discrepancy on [DATE]. Resident A: On [DATE], $20.00 was receipted in by Receptionist #1, and not posted to the trust fund account. On [DATE], $20.00 was credited to resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident B: On [DATE], $20.00 was receipted by Receptionist #1 but was not posted to the resident's trust account: an undated receipt # 5 for $20.00 was receipted by Receptionist #1 but the funds were no posted to the resident's trust account: on [DATE] in the amount of $20.00 receipted by receptionist #1 but was not posted to the resident's trust account. On [DATE], $60.00 was mailed to resident's address. The RP was notified of the discrepancy on [DATE]. Resident C: On [DATE], $10.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident D: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were deposited in resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident E: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident F: On [DATE], $12.50 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust account. The RP was notified of the discrepancy on [DATE]. Resident G: On [DATE], $80.00 cash was receipted by receptionist #1 with only $60.00 deposited into the resident's trust account for a discrepancy of $20.00: On [DATE] cash was receipted by receptionist #1 in the amount of $40.00 but not posted to the resident's account; On [DATE] cash was receipted by receptionist #1 in the amount of $40.00 but not posted to the resident's account; On [DATE], $100.00 was credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident H: On [DATE], $50.33 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident I: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], $50.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident J: On [DATE], $60.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident K: On [DATE], $4.00 cash was receipted by BOM but was not posted to the resident's trust fund account: On [DATE], $30.00 cash was receipted by receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident L: On [DATE], a cash deposit receipt for $19.00 was altered and signed by Receptionist #1, however only $9.00 was deposited to the resident's account: On [DATE], $1.92 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident M: On [DATE], $22.73 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were deposited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident N: On [DATE], $2.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident O: On [DATE], $0.25 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to RP. The RP was unavailable when contacted of the discrepancy on [DATE], but was notified on [DATE]. Resident P: On [DATE], $7.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's tru

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure residents trust fund accounts for nine (9) of thirteen (13) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8 and #13), from a total of 13, to include 18 of 18 Unsampled Residents (Unsampled Residents #A, #B, #C, #D, #E, #F, #G, #H, #I, #J, #K, #L, #M, #N, #O, #P, #Q and #R) were held, safeguarded, managed and accounted for. This resulted in Immediate Jeopardy that began on [DATE], after $1580.98 was found missing from 26 different resident trust fund accounts, with the likelihood of personal financial loss and the associated mental anguish. Findings include: During an interview [DATE] at 10:20 a.m., the facility's Regional Director of Business Office Services #1 said she was called to the facility and began an audit [DATE] that revealed $1580.98 was missing from 26 various resident trust fund accounts. Resident #1 Record review of the face sheet dated [DATE] revealed Resident #1 was a [AGE] year old female admitted to the facility [DATE] and she remained at the facility. Review of the trust fund balance record revealed the an account was opened [DATE], had a zero balance until [DATE], and remained active. An audit conducted [DATE] revealed $40.00 had never been credited to the trust fund account, despite cash receipts dated: 1) [DATE] in the amount of $20.00; and 2) [DATE] in the amount of $20.00. Resident #2 According to the face sheet dated [DATE], Resident #2 was a [AGE] year old female admitted to the facility [DATE] and she remained at the facility. Review of the trust fund balance record revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $25.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $25.00. Resident #3 Review of the resident's face sheet dated [DATE] revealed Resident #3 was a [AGE] year old female admitted to the facility [DATE] and she remained at the facility. Review of the trust fund balance record revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $13.25 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $13.25. On [DATE] at 2:30 p.m., the following debits were audited and found to be classified as beauty shop payments from Resident #3's trust fund account, however the facility had no documented evidence to support the debited services were rendered on: 1) [DATE] in the amount of $10.00; 2) [DATE] in the amount of $10.00; 3) [DATE] in the amount of $10.00; and 4) [DATE] in the amount of $10.00. During an interview [DATE] at 2:30 p.m., Regional Director of Business Office Services #1 said it may be due to bad record keeping, or miss filing, but the receipts and/or sign in sheets for the beauty salon dated [DATE], [DATE], [DATE] and [DATE] could not be located to verify Resident #3 had received the services debited from her account. Resident #4 Record review revealed Resident #4 was a [AGE] year old male admitted to the facility [DATE] and he remained at the facility. Review of the trust fund balance record revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $40.50 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of $6.50; 2) [DATE] in the amount of $14.00; 3) [DATE] in the amount of $10.00; 4) [DATE] in the amount of $5.00; and 5) [DATE] in the amount of $5.00. Resident #5 Review of the closed record face sheet dated [DATE] revealed Resident #5 was a [AGE] year old male admitted to the facility [DATE] and he died at the facility on [DATE]. Review of the trust fund balance record revealed the account was opened [DATE] and was closed [DATE]. An audit conducted [DATE] revealed $400.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $400.00. Resident #6 Review of the closed records face sheet dated [DATE] revealed Resident #6 was a [AGE] year old male admitted to the facility [DATE] and he was discharged to another facility on [DATE]. Review of the trust fund balance record revealed the account was opened [DATE] and was closed [DATE]. An audit conducted [DATE] revealed $200.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $200.00. Resident #7 According to the face sheet dated [DATE], Resident #7 was a [AGE] year old female readmitted to the facility [DATE] and she remained at the facility. Review of the trust fund balance record revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $122.00 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of $20.00; 2) [DATE] in the amount of $15.00; 3) [DATE] in the amount of $20.00; 4) [DATE] in the amount of $37.00; 5) [DATE] in the amount of $10.00; and 6) [DATE] in the amount of $20.00. Resident #8 According to Resident #8's face sheet dated [DATE], he was a [AGE] year old male readmitted to the facility on [DATE] and he died at the facility on [DATE]. Review of facility trust fund balance records revealed staff never opened a resident trust fund account for Resident #8. An audit conducted [DATE] revealed $220.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $220.00. Resident #13 According to the face sheet dated [DATE] Resident #13 was a [AGE] year old female who was admitted to the facility [DATE] and she was readmitted on [DATE]. According to facility records reviewed on [DATE], Resident #13 had an active resident trust fund. During an interview on [DATE] at 5:00 p.m. Resident #13 was alert and oriented and said she was responsible for her own medical and financial decision making. Resident #13 said she had had never received a financial statement from the facility informing her of the balance of and transactions made related to her trust fund. Unsampled Resident #A Record review revealed Unsampled Resident #A was an [AGE] year old female readmitted to the facility [DATE] and she remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $20.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $20.00. Unsampled Resident #B According to the face sheet dated [DATE], Unsampled Resident #B was a [AGE] year old female admitted to the facility [DATE] and she was discharged to another facility on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] with a zero balance [DATE]. An audit conducted [DATE] revealed $60.00 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) ,[DATE] in the amount of 20.00; 2) [DATE] in the amount of $20.00; and 3) [DATE] in the amount of $20.00. Unsampled Resident #C According to the resident's face sheet dated [DATE], Unsampled Resident #C was an [AGE] year old female admitted to the facility [DATE] and she remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $10.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $10.00. Unsampled Resident #D Record review of the face sheet dated [DATE], Unsampled Resident #D was a [AGE] year old male admitted to the facility [DATE] and he remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $20.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $20.00. Unsampled Resident #E According to the face sheet dated [DATE], Unsampled Resident #E was a [AGE] year old male admitted to the facility [DATE] and he was discharged home on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and closed [DATE]. An audit conducted [DATE] revealed $20.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $20.00. Unsampled Resident #F According to the face sheet dated [DATE], Unsampled Resident #F was a [AGE] year old male admitted to the facility [DATE] and he was readmitted [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $12.50 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $12.50. Unsampled Resident #G According to the face sheet dated [DATE], Unsampled Resident #G was an [AGE] year old male admitted to the facility [DATE] and died at the facility [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $100.00 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of 20.00; 2) [DATE] in the amount of $40.00; and 3) [DATE] in the amount of $40.00. Unsampled Resident #H Record review revealed Unsampled Resident #H was a [AGE] year old female admitted to the facility [DATE] and readmitted on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $50.33 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $50.33. Unsampled Resident #I According to the face sheet dated [DATE], Unsampled Resident #I was a [AGE] year old female admitted to the facility [DATE] and discharged home on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and closed [DATE]. An audit conducted [DATE] revealed $70.00 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of 20.00; and 2) [DATE] in the amount of $50.00. Unsampled Resident #J According to the face sheet dated [DATE], Unsampled Resident #J was an [AGE] year old female admitted to the facility [DATE] and discharged home on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $60.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $60.00. Unsampled Resident #K According to Unsampled Resident #K face sheet dated [DATE], he was an [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $34.00 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of $30.00; and 2) [DATE] in the amount of $4.00. Unsampled Resident #L According to the face sheet dated [DATE], Unsampled Resident #L was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $20.92 had never been credited to the resident's trust fund account, despite cash receipts dated: 1) [DATE] in the amount of $1.92; and 2) [DATE] in the amount of $19.00. However, on an unknown date, at an unknown time, the carbon copy of the second receipt was altered to signify $9.00 had been deposited, not $19.00. Unsampled Resident #M Record review of the resident's face sheet dated [DATE] revealed Unsampled Resident #M was a [AGE] year old female admitted to the facility [DATE] and readmitted on [DATE]. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $22.73 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $22.73. Unsampled Resident #N According to the face sheet dated [DATE], Unsampled Resident #N was a [AGE] year old male admitted to the facility [DATE] and remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $2.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $2.00. Unsampled Resident #O Record review of the resident's face sheet dated [DATE] revealed Unsampled Resident #O was an [AGE] year old female admitted to the facility [DATE] and died at the facility on [DATE]. Review of facility trust fund balance records revealed staff never opened a trust fund account for Unsampled Resident #O. An audit conducted [DATE] revealed $0.25 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $0.25. Unsampled Resident #P According to the face sheet dated [DATE], Unsampled Resident #P was a [AGE] year old male admitted to the facility [DATE] who remained at the facility. Review of facility trust fund balance records for Unsampled Resident #P revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $7.00 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $7.00. Unsampled Resident #Q According to the face sheet dated [DATE], Unsampled Resident #Q was a [AGE] year old male admitted to the facility [DATE] who remained at the facility. Review of facility trust fund balance records revealed the account was opened [DATE] and remained active. An audit conducted [DATE] revealed $11.00 had never been credited to the resident's trust fund account, despite an undated cash receipt in the amount of $11.00. Unsampled Resident #R According to the face sheet dated [DATE], Unsampled Resident #R was a [AGE] year old female admitted to the facility [DATE] who remained at the facility. Review of facility trust fund balance records revealed Unsampled Resident #R's account was opened [DATE] and remained active. An audit conducted [DATE] revealed $8.50 had never been credited to the resident's trust fund account, despite a cash receipt dated [DATE] in the amount of $8.50. Review of the facility's policy entitled "Financial Services Business Office", dated [DATE], revealed "Receipt books are to be kept secure in a locked cabinet." Observations made of the front office where the residents' trust fund cash box was kept, on [DATE] at 12:15 p.m. revealed the office was left unattended at times and not locked, easily accessible from the lobby. The key to the trust fund cash box was left unsecured at the receptionist desk, next to the filing cabinet that housed the locked cash box. Receipt books for credits and debits from the trust fund were left unsecured on the top of the same two tier filing cabinet. During an interview [DATE] at 2:30 p.m. with Regional Director of Business Office Services #1, revealed facility practice prior to [DATE] permitted one (1) staff member (RC#1 - Receptionist #1) to receipt, debit, credit, and audit all resident trust fund accounts. Regional Director of Business Office Services #1 said to meet facility policy and current standards of practice in accounting the facility was required to segregate these aforementioned tasks to different staff members. When asked if the policy was enforced once the facility identified money missing from resident trust fund accounts on [DATE], Regional Director of Business Office Services #1 said no. Regional Director of Business Office Services #1 said RC #1 (Receptionist) was hired in ,[DATE] to manage resident trust fund accounts but no documented evidence existed to suggest her work was never audited before $1580.98 was found missing on [DATE]. Regional Director of Business Office Services #1 said the monthly report she received from the facility did not meet audit criteria. They were simply printed account statements without evidence to support the transactions. Regional Director of Business Office Services #1 said, "Some of it may just be sloppy book keeping." During an interview [DATE] at 11:00 a.m., the Business Office Manager (BOM #1) said her current practice permits her access to resident accounts, receipt of funds, and deposit responsibilities for all resident trust fund accounts. The BOM #1 was then instructed to read the second line of the facility's policy entitled "Financial Services Business Office", dated [DATE], which stated "No business office employee who has access to residents' accounts will be allowed to receipt monies, prepare deposits, or make deposits at the bank." BOM #1 then stated she and other staff members were unable to follow the current policy because they were short staffed. The facility's policy entitled "Financial Services Business Office", dated [DATE], documented "Money received at the facility will be properly receipted and deposited on a daily basis." The procedure listed in this policy documented "Monies received should be put in a box and locked in the facility safe at the end of each day." During an interview [DATE] at 12:00 p.m., Medical Records (MR) #1 said when she received cash for resident trust funds it was placed it in the cash box overnight and left for another staff member (RC #1) to process the payment. During an interview [DATE] at 2:00 p.m., Social Worker (SW) #1 said since her office moved ,[DATE], she passed off any funds received for resident trust funds to another staff member Receptionist (RC) #1 to process the payment. During an interview [DATE] at 1:30 p.m., RC #1 said she was responsible for the "RFMS" otherwise known as the "Resident Fund Management System." RC #1 said cash received for resident trust funds generated a triplicate receipt and were stored in an office lock box sometimes for days. RC #1 said the duration depended on her ability to leave the facility unattended with the cash deposits, to obtain a money order from the local post office. RC#1 said the facility trained her to disperse the triplicate receipts with: 1) The original provided to the payer; 2) The second or "yellow" copy placed with the cash, in the cash box; and 3) The third or "pink" receipt was to be kept in the receipt book. RC #1 said there were days she was too busy to follow this process and when residents' and/or their responsible party requested the deposited cash back before it was posted to their account, she simply returned the funds and discarded the yellow receipt. RC #1 denied ever generating a receipt for funds withdrawal in those circumstances. RC #1 added it was "probably not the proper way to do it." On [DATE] at 6:30 p.m., Executive Director (ED) #1 said she was relatively new to the facility, hired on [DATE], but was not the active Administrator present in the building until [DATE]. ED #1 expected a problem because the cash box key was left unsecured and too many hands touched the money. ED #1 failed to provide any interventions implemented after she identified the concern to safeguard the residents trust fund accounts. The Administrator was informed on [DATE] at 3:30 p.m., of the Immediate Jeopardy identified [DATE], that began between [DATE] when the facility failed to prevent misappropriation of resident trust fund accounts resulting in the likelihood of personal financial loss and the associated mental anguish. The facility submitted the following credible Allegation of Compliance (AoC) on [DATE] at 2:15 p.m.: "On [DATE] at 4:30 p.m., BOM, identified a financial discrepancy and reported it to the Executive Director. The discrepancy was for 2 cash receipts signed by receptionist #1 dated [DATE] for 443.13 and [DATE] for $702.00. These were never posted to the residents Room & Board (Operations) Account. RDBOS (Regional Director of Business Services) was notified on [DATE] at 7:50 a.m. by BOM. RDBOS arrived at the facility [DATE] around 10:00 a.m. and began an operating account audits. RDBOS notified, Regional Vice President of Operations and District Business Office Services that discrepancies in operating accounts had been identified. Due to the discrepancies, found an audit of Resident Trust Fund Accounts with cash receipts began [DATE] at 9:30 a.m., by the RDBOS. The audit was completed on [DATE] at 6:00 p.m. 26 of 126 residents trust fund accounts with cash deposits had discrepancies. On [DATE] a request was made to Consulate Management Services for the 26 resident trust fund accounts to be credited for any accounting discrepancy for total amount of $1580.98. The results of the audit were as follows: Resident #1: On [DATE], $20.00 was receipted by Receptionist #1 but not posted to the resident's trust account. On [DATE], $20.00 was receipted by MR but not posted to the resident's account. On [DATE], $40.00 was credited to the resident's trust fund account. The Responsible Party was notified of the discrepancy on [DATE]. Resident #2: On [DATE], $25.00 receipted by receptionist #1, but was not posted to the resident's trust account. On [DATE] $25.00 was credited to the trust account. The RP was notified of the discrepancy on [DATE]. Resident #3: On ,[DATE], $13.25 was receipted by receptionist #1, but was not posted to the resident's trust account. On [DATE], $13.25 was credited to the trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #4: On [DATE], $6.50 was receipted by Receptionist #1 but not posted to the resident's trust account: On [DATE], in the amount of $14.00 was receipted by receptionist #1 but not posted to the resident's trust account. On [DATE], $5.00 receipted by receptionist #1 but was not posted to the resident's trust account; on [DATE], $10.00 receipted by Receptionist #1 but was not posted to the resident's trust account; on [DATE], $5.00 receipted by receptionist #1 but was not posted to the resident's trust account. On [DATE], $40.50 was credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #5: On [DATE], $400.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], a check was mailed to resident's RP. The RP was notified of the discrepancy on [DATE]. Resident #6: On [DATE], $200.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident #7: On [DATE], $20.00 cash was receipted by the former Executive Director but was not posted to the resident's trust account: On [DATE], $15.00 cash was receipted by the former admission coordinator but was not posted to the resident's trust account: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $37.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $10.00 cash was receipted by the medical records clerk but was not posted to the resident's trust account: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust account: On [DATE], $122.00 credited to the residents trust fund account. The RP was notified of the discrepancy on [DATE]. Resident #8: On [DATE], $220.00 cash was receipted by receptionist #1 but was not posted to the resident's trust account: On [DATE], funds were mailed to resident's RP. The RP was notified of the discrepancy on [DATE]. Resident A: On [DATE], $20.00 was receipted in by Receptionist #1, and not posted to the trust fund account. On [DATE], $20.00 was credited to resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident B: On [DATE], $20.00 was receipted by Receptionist #1 but was not posted to the resident's trust account: an undated receipt # 5 for $20.00 was receipted by Receptionist #1 but the funds were no posted to the resident's trust account: on [DATE] in the amount of $20.00 receipted by receptionist #1 but was not posted to the resident's trust account. On [DATE], $60.00 was mailed to resident's address. The RP was notified of the discrepancy on [DATE]. Resident C: On [DATE], $10.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident D: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were deposited in resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident E: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident F: On [DATE], $12.50 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust account. The RP was notified of the discrepancy on [DATE]. Resident G: On [DATE], $80.00 cash was receipted by receptionist #1 with only $60.00 deposited into the resident's trust account for a discrepancy of $20.00: On [DATE] cash was receipted by receptionist #1 in the amount of $40.00 but not posted to the resident's account; On [DATE] cash was receipted by receptionist #1 in the amount of $40.00 but not posted to the resident's account; On [DATE], $100.00 was credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident H: On [DATE], $50.33 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust accounts. The RP was notified of the discrepancy on [DATE]. Resident I: On [DATE], $20.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], $50.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident J: On [DATE], $60.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to the resident's RP. The RP was notified of the discrepancy on [DATE]. Resident K: On [DATE], $4.00 cash was receipted by BOM but was not posted to the resident's trust fund account: On [DATE], $30.00 cash was receipted by receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident L: On [DATE], a cash deposit receipt for $19.00 was altered and signed by Receptionist #1, however only $9.00 was deposited to the resident's account: On [DATE], $1.92 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident M: On [DATE], $22.73 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were deposited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident N: On [DATE], $2.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident O: On [DATE], $0.25 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were mailed to RP. The RP was unavailable when contacted of the discrepancy on [DATE], but was notified on [DATE]. Resident P: On [DATE], $7.00 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust fund account. The RP was notified of the discrepancy on [DATE]. Resident Q: On [DATE], an undated receipt # 5 in the amount of $11.00 for cash was issued but not posted to the resident's account. On [DATE] $11.00 was credited to the resident's trust fund. The RP was notified of the discrepancy on [DATE]. Resident S: On [DATE], $8.50 cash was receipted by Receptionist #1 but was not posted to the resident's trust fund account: On [DATE], funds were credited to the resident's trust account. The RP was notified of the discrepancy on [DATE]. The residents were not aware of the balance discrepancies in their trust fund account, because the residents were not affected by the discrepancies, meaning that no resident attempted to withdraw money and no one received a letter relating a balance owed to the facility. On [DATE] at approximately 8:00 a.m., Receptionist #1 was suspended by BOM, pending the results of the audits and subsequent investigations. On [DATE] the DON called and submitted the incident to the required State Licensure Report by telephone. On [DATE] a surveyor from the State Licensure and Certification agency arrived to conduct an ongoing investigation. On [DATE] DCS notified the McComb Police Department of the audit findings, a detective responded. An official police report was filed on [DATE]. On [DATE] DCS notified the State Attorney General's office of trust fund discrepancies. On [DATE] an investigator from the Attorney General's office arrived to the facility and initiated an ongoing investigation. The investigator reported an audit would be conducted by their office and the facility would receive the results. The facility awaits the auditor and findings. On [DATE] @ 11am written report faxed to State Department of Health by DCS. On [DATE] at 1:30 p.m., Receptionist #1's employment was terminated by the ED, for failure to follow facility policy and procedures for Resident Trust Funds. On [DATE] at 5:00 p.m., the policy's for: 1) cash receipts - BO-202; 2) resident's rights-SS-260; and 3) misappropriation of property-N-1265, were reviewed by the ED, RDBOS, BOM, and DON. The three policies were deemed appropriate. No changes were made in the policies and procedures. Mandatory in-services were held on [DATE] at 5:00P.M., 7:00P.M., 10:30 P.M. and on [DATE] at 6:45 A.M. for all facility and contracted employees. The content of the education included education on facility policies for resident right's, misappropriation of funds and property, and policies relating to trust funds (See attached policies). No staff were permitted to return to active duty as of [DATE], until they received the mandatory in-service conducted by the RDBOS. 148 of 148 (100%) of staff

CI MS #9957 Based on record review, staff interview and policy review, the facility failed to: 1) Ensure that Resident #1 received adequate supervision and assistance to prevent accidents/injury requiring hospitalization with surgery, 2) Report Resident #1's fall on 11/5/11 to the supervisor; and, 3) Assess Resident #1 timely. This is for one (1) of three (3) residents reviewed, Resident #1. Resident #1 reported to Certified Nursing Assistant (CNA #3) on the morning of 11/5/11 that he (Resident #1) had fallen in the shower earlier that day, hurt his hip and was in pain. Resident #1 sustained a left hip fracture and required surgery as a result of the fall on 11/5/11. Findings Include: On 11/9/11 the State Agency (SA) received a facility self reported incident of neglect. Review of the facility submitted documentation revealed that on 11/5/11 Resident #1 was complaining of leg pain. Resident #1 reported that he fell while in the shower room and that his CNA had put him back to bed. Resident #1 reported that the fall occurred just prior to the 7 a.m. shift. CNA #1 (Resident #1's assigned CNA for the 11-7 shift on 11/4/11) initially stated that Resident #1 had told her he had bumped his leg on the tub while sitting in the shower room and that she (CNA #1) had reported this to the nurse. The facility determined that a second CNA (CNA #2) was asked by CNA #1 to assist her with Resident #1. CNA #2 reported that when she went to the shower room Resident #1 was on the floor. CNA #1 and CNA #2 assisted Resident #1 up and into a wheelchair (wc) and to his bed. CNA #2 stated that CNA #1 stated that she would tell the nurse. CNA #1 was questioned again about the 11/5/11 fall and CNA #1 admitted that Resident #1 had fallen in the shower room. CNA #1 stated that she left Resident #1 unattended while she (CNA #1) made up his bed, and Resident #1 was on the floor when she returned. The facility terminated CNA #1 on 11/8/11 due to confirmed neglect on Resident #1. CNA #1 and CNA #2 failed to report the fall of Resident #1. CNA #1 reported that Resident #1 had bumped his leg on the tub in the shower to Licensed Practical Nurse (LPN) #1 on 11/5/11 and LPN #1 failed to assess Resident #1 for injury. Resident #1 sustained a left hip fracture as a result of the fall on 11/5/11. Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #1 did not occur as Resident #1 was discharged to another nursing facility. Review of Resident #1's 30-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/11 revealed that Resident #1's Brief Interview for Mental Status (BIMS) score was 12. This score on a scale of 8-12 represents moderate cognitive impairment for daily decision-making skills. Resident #1 was coded as limited assistance of one (1) person for transfers, ambulation and dressing. Resident #1 was coded as extensive assistance of two (2) persons for toileting and personal hygiene. Resident #1 was coded a two (2) which represents not steady, only able to stabilize with human assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet and transfer between bed and chair. Review of Resident #1's Admission Data Collection dated 9/9/11 revealed that Resident #1 was a high risk for falls related to history of falls prior to admission. Review of Resident #1's nursing care plan 9/9/11 revealed a problem for "Potential for falls R/T (related to) history of falls prior to admission, weakness and decline in ADL'S (Activity of Daily Living). Approaches listed "*keep call light in reach *give assist with transfers *observe for attempts to get up by himself." Review of Physical Therapy (PT) Treatment Notes with a start of care date of 9/30/11 revealed a [DIAGNOSES REDACTED]. (patient) with gt (gait) training with some wobbling today. Pt. with ed (education) to increase step strength and placement to keep from drifting side to side." Review of a 24 Hour report for Resident #1, dated 11/4/11, revealed "increased confusion noted, CNA reported that resident bumped his leg after shower but no open areas or bruise noted." Another 24 Hour report for Resident #1, dated 11/5/11 revealed "fall in shower-c/o (complains of pain) transferred to (name) local hospital-admit with hip fx (fracture)." Review of Resident #1's "Physician's Telephone Orders", dated 11/5/11 at 7:45 a.m., revealed "transfer to (name) local ER for eval r/t fall/hip pain." A "Physician's Telephone Orders" at 10:40 a.m., revealed "Admit to (local hospital) dx (diagnosis) hip fx (fracture)." Review of a emergency room (ER) report, dated 11/5/11 at 8:50 a.m., revealed documentation of a fall prior to arrival in the ER. Resident #1's exam in the ER revealed left hip pain, with shortening of the left leg. An x-ray report, dated 11/5/11, revealed "Intratrochanteric fracture of the left hip along the inferior trochanteric margin." Interview with the Director of Nursing (DON) on 1/4/12 at 8:45 a.m., revealed that on 11/5/11 when the 7-3 shift came on duty, Resident #1 was c/o of left hip pain and reported that he (Resident #1) had fallen in the shower to CNA #3. Resident #1 also reported that CNA #1 and CNA #2 had got him up into the wheelchair then to bed. The DON stated that when she questioned CNA #1, CNA #1 denied that Resident #1 had fallen in the shower. The DON stated that when she questioned CNA #2, CNA #2 stated that CNA #1 had called her for help with Resident #1. CNA #2 stated that when she got to the shower room Resident #1 was on the floor. The DON stated that CNA #2 told her that she (CNA #2) told CNA #1 that the nurse needed to be notified first to check Resident #1. The DON stated that CNA #1 told CNA #2 that she had already told the nurse and the nurse had checked Resident #1 and would check him again later. The DON stated that CNA #1 and CNA #2 placed Resident #1 into a wheelchair and then to bed. The DON stated that CNA #2 believed that CNA #1 had made a report of the fall and did not make a report herself. The DON stated that when CNA #1 was questioned again, CNA #1 admitted that Resident #1 had fallen in the shower room. The DON stated that CNA #1 admitted that she had left Resident #1 alone in the shower room and did not report the fall to the nurse. The DON stated that CNA #1 was terminated for neglect of Resident #1. The DON stated that CNA #2 was written up for failing to report a fall and writing a statement of the incident. The DON stated that it is not facility practice to leave any resident unattended and that the staff are trained on reporting incidents. Interview with CNA #1 on 1/4/12 at 10:22 a.m., revealed that CNA #1 stated that she had left Resident #1 in the straight chair of the shower room, left the shower room door opened and went to make Resident #1's bed. CNA #1 stated that she heard Resident #1 call out "help" and when she went back to the shower room Resident #1 was on the floor. CNA #1 stated that she asked CNA #2 to help get Resident #1 into the wheelchair and then to bed. CNA #1 stated that Resident #1 did c/o his leg being sore. CNA #1 admitted that she did not report the fall incident for Resident #1 to the nurse that morning. CNA #1 stated that it was not facility protocol to leave any resident unattended and that any incident had to be reported. CNA #1 stated that she had been trained on the facility policy for reporting and falls. CNA #1 stated that she denied the incident and gave false information to the nurse as she was nervous. CNA #1 admitted that leaving Resident #1 alone in the shower room and not reporting the incident was wrong and added "my mistake, I'm sorry." Interview with CNA #2 on 1/4/12 at 10:50 a.m., revealed that she received a call from CNA #1 around 6 a.m. that she (CNA #1) needed help with Resident #1. CNA #2 stated that when she got to the shower room Resident #1 was on the floor. CNA #2 stated that CNA #1 told her that Resident #1 was transferring from the shower chair to the chair and bumped his knee on the tub and just slid to the floor. CNA #2 stated that she assisted CNA #1 to get Resident #1 up from the floor to the wheelchair and then to his bed. CNA #2 stated that Resident #1 did complain of pain to his leg and told CNA #1 that she (CNA #1) needed to report this to the nurse. CNA #2 stated that CNA #1 stated "no, he is okay." CNA #2 stated that she believed what CNA #1 told her had happened, so she (CNA #2) did not make a report to the nurse herself. CNA #2 stated that she had been trained on the facility policy for reporting and falls and that residents are never to be left unattended. Interview with CNA #3 on 1/4/12 at 11:25 a.m., revealed that staff are trained on safety, falls, and reporting incidents. CNA #3 stated that resident's are never to be left alone and all incidents are to be reported, even if a co-worker states they have reported CNA #3 stated she makes a report as well so nothing is missed. Interview with RN #1 on 1/4/12 at 11:50 a.m,. revealed that she received a report from CNA #3 that Resident #1 stated he needed to go to the hospital as he had fallen and broke his hip. RN #1 stated that in report that morning she (RN #1) received information that Resident #1 had bumped his hip in the shower. RN #1 stated that on assessing Resident #1 it was obvious that his hip was fractured as the left leg was flexed and externally rotated and Resident #1 was c/o pain to the hip. RN #1 stated that the ambulance was called and Resident #1 was admitted to the hospital with [REDACTED]. Interview with LPN #1 on 1/4/12 at 12:50 p.m., revealed that CNA #1 reported to her that Resident #1 had bumped his leg after his shower and that CNA #1 reported to her that there was no open area or bruise. LPN #1 stated that she did not assess Resident #1 after receiving this report, she took CNA #1's word that Resident #1 was okay. LPN #1 stated that when CNA #3 was putting out breakfast trays on the morning of 11/5/11 that Resident #1 reported to CNA #3 that he had fell . LPN #1 stated that RN #1 assessed Resident #1 and stated that Resident #1's left hip appears broke. LPN #1 stated that CNA #1 and CNA #2 never reported to her that Resident #1 had a fall or even complained about pain. LPN #1 stated that she should have checked Resident #1 when CNA #1 reported that Resident #1 bumped his leg in the shower that morning, but did not as she took CNA #1's word that Resident #1 was okay. Review of an incident report for Resident #1, dated 11/5/11 completed by LPN #1, revealed documentation that Resident #1 sustained a fall at 5:50 a.m. on 11/5/11 in the shower room. There is no documented evidence of this fall or an observation of Resident #1 related to this fall in the medical record at this time. Review of a Change in Condition Evaluation for Resident #1, dated 11/5/11 with a time of 7:45 a.m., revealed "fall-c/o hip pain and an assessment documented by RN #1 at that time. Review of CNA #1's initial hand written signed statement, dated 11/4/11, revealed "When I went in the bathroom I saw (Resident #1) bent over in the shower chair he said he hurt his leg on the whirlpool tub. It seems as though he was trying to put his shoes and socks on. I brought his can in the bathroom and asked if he could get up so we could go to the room he said no my side hurts. So I said I can't lift you out the shower chair and I will get some help to lift you from the chair cause he said he was hurting. Me and (CNA #2) lift him from shower chair to wheelchair and took him to room and put him in bed." Review of CNA #1's second hand written signed statement, dated 11/4/11, revealed "I took (Resident #1) to the shower about 5:00 a.m.. I assist him with his shower. When finished he started to put his clothes on so I went to his room to change linen on his bed. On my way back to shower room I heard someone say help. I go in shower room and find (Resident #1) on floor. I asked (CNA #2) for help to get him up and we put him in wheelchair. Took (Resident #1) to his room and put him in bed. He complained of side being sore and hurting. I didn't know it was severe to have him unable to move leg." Review of CNA #2's hand written signed statement, dated 11/5/11, revealed "I was in room (number) giving care to resident went (when) (CNA #1) came in and asked me to help her (Resident #1) in the shower. I said ok as soon as I finish with (resident name) because she came in the middle of me changing her. She (CNA #1) said she think he (Resident #1) bumped his leg on tub when he was getting out of the shower chair on to the regular chair that he needed help. When I got to the shower room he (Resident #1) was lying on the floor in front of the tub. I told her (CNA #1) to leave him on the floor and get the nurse to look at him that he maybe hurt and may need observations so he can be sent out. She (CNA #1) said she don't think he is hurt just help me get him up and get his socks and shoes on. I helped her (CNA #1) get him (Resident #1) up and on the regular chair and I went and got a wheelchair and helped get him (Resident #1) on the wheelchair and then to his room and then to his bed. He (Resident #1) laid down and I returned to my end and finished my residents." Review of LPN #1's hand written signed statement, dated 11/5/11 at 5:30 a.m., revealed "CNA's (CNA #1 and CNA #2) floor nurse heard them say he hit his leg. I asked was he bleeding. Neither one of them said anything about him falling. (CNA #1) came back to nursing home. She said she knew nothing of him falling." Review of CNA #3's hand written signed statement, dated 11/5/11, revealed "I came on to the IC hall with my breakfast trays went to room (number) to (Resident #1) room, gave him his breakfast tray "He said, what can I do to get a doctor in here, I said "I will tell the nurse that want to see a doctor, but she needs to know what is wrong with you to get a Dr. for you." He said "I fell in the shower and hurt my hip, I believe my hip broke, I'm in pain." Review of RN #1's hand written signed statement, dated 11/5/11 at 7:30 a.m., revealed "Notified by (CNA #3) that while putting out breakfast trays, (Resident #1) told her (CNA #3) he had fallen in the shower this am and thinks he broke his hip. Resident was lying supine with (L) (left) leg flexed at knee and externally rotated. Resident called out in pain upon palpation of (L) hip. States it "hurts worse here" and touched groin area. Movement increased level of pain. Resident stated he "fell over when I was taking my shower" and that he was brought to room via (by way of) wheelchair and placed in bed." Review of a facility policy "Fall Risk Reduction and Management", with a revised date of 8/10, revealed "Overview- The facility strives to prevent resident/patient falls and injury while at the same time promoting and supporting resident/patient mobility. All residents/patients are considered to be at risk for falling. Post fall management includes appropriate resident/patient care, evaluation and revision of existing interventions and investigation into potential factors to determine areas of improvement." Review of a facility policy "Fall Management", with a revised date of 8/10, revealed "Fall management includes: provision of immediate care for injuries, evaluation of clinical condition to determine need for medical intervention, review of fall risk indicators and evaluation and/or modification of interventions; notification of physician and family/responsible party and reporting process. Procedure 1. Provide immediate care and services to the resident/patient to identify and treat any injuries, and verify resident/patient safety. Avoid moving resident/patient until injury evaluation is complete and it is determined that it is clinically appropriate to move resident/patient." Review of the facility policy "Abuse Prevention Program", with a revised date of 2/05, revealed "The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to: staff, family, or friends. Employees are appropriately screened and trained to prevent abuse. Each employee is responsible to report any suspected abuse. Each incident will be investigated, and required reporting completed. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Reporting 1. Notify the Shift Supervisor immediately if suspected abuse, neglect, mistreatment or misappropriation of property occurs. Report the incident to the Administrator, Director of Nursing, or designee." Review of facility policy "Accidents/Incidents", (not dated), used for employee training revealed "All accidents/incidents occurring on nursing home property must be reported. Regardless of how minor the accident, you must report it to your supervisor. If you witness an accident/incident you must report this to your supervisor. The Charge Nurse will complete an accident/incident report which will require your input. Injuries must be reported on the shift in which they occurred but no later than within 48 hours of occurrence."

CI MS #9957 Based on record review, staff interview and policy review, the facility failed to ensure that one (1) of three (3) residents, Resident #1, was free from neglect. Resident #1 reported to Certified Nursing Assistant (CNA #3) on the morning of 11/5/11 that he (Resident #1) had fallen in the shower earlier that day, hurt his hip and was in pain. Resident #1 sustained a Intratrochanteric [MEDICAL CONDITION] hip, requiring hospitalization with surgery. Findings Include: Cross Refer to F-323 for the facility's failure to: 1) Ensure that Resident #1 received adequate assistance to prevent neglect with injury requiring hospitalization with surgery, 2) Report Resident #1's fall on 11/5/11 to the supervisor; and, 3) Assess Resident #1 timely.