Every finding on record at Creekview Health and Rehabilitation

Based on facility policy review, observations, and interviews, the facility failed to ensure two dietary aides had a protective facial hair covering while working in the kitchen, failed to ensure food items were properly labeled (name, date opened, or expiration date), failed to ensure frozen food items were stored at a temperature for frozen food items to remain frozen solid which had the potential to affect 71 of 72 residents, and failed to ensure an expired nutritional supplement was discarded and unavailable for resident use on 1 of 2 medication carts observed.The findings include:Review of the facility's policy titled, Sanitary Standards-Dietary Personnel, revised 7/2016, revealed .It is the policy of this facility .dietary personnel will be required to follow additional sanitary standards .Hair restraints .beard restraint .must be worn at all times while in the kitchen .Review of the facility's policy titled, Food Storage, revised 8/2019, revealed .It is the policy of this facility .Foods shall be labeled, dated .Dates used may be a date prepared/opened and/or used by date .Review of the facility's policy titled, Food Safety, revised 5/2020, revealed .All local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department .Food .stored is protected from .growth of any pathogenic organisms .Foods are frozen and stored at a temperature that keeps them frozen solid .Foods with expiration dates are used prior to the use by date on the package .During an observation and interview on 9/28/2025 at 10:00 AM, with the Certified Dietary Manager (CDM) revealed visible facial hair for Dietary Aide (DA) E and DA F and did not have a facial hair covering in place. The CDM stated it was her expectation for all dietary staff with visible facial hair to have a facial hair covering in place while in the kitchen. The CDM confirmed DA E and DA F had visible facial hair and were not wearing a facial hair covering while in the kitchen. During an observation and interview in the dry food storage area on 9/28/2025 at 10:04 AM with the CDM, revealed a 6 quart clear plastic container which contained a 1/3 of dry cereal, was not labeled with the name of the item, and did not have an open date, discard date, or expiration date. The CDM confirmed the 6 quart clear plastic container which contained 1/3 dry cereal was not labeled with the name of the food item and did not include an open date, discard date, or expiration date. During an observation and interview in the walk-in refrigerator on 9/28/2025 at 10:08 AM with the CDM, revealed 14 packages of meat stored in the walk cooler with no label to identify the meat and no expiration date. The CDM confirmed the 14 packages of meat were not labeled to identify the meat and did not have an expiration date. During an observation and interview on 9/28/2025 at 12:56 PM with the CDM, revealed the thermometer in the walk-in freezer read 30 degrees. Further observation revealed the following freezer food items including 27 salisbury steaks, 40 porkchops, a 3 pound bag of sweet potato puffs, 94 cinnamon rolls, 5 boneless pork chops, (2) 10 pound cases of fully cooked rib- shaped pork patties, 8 bone in pork chops, 10 pound case of uncooked chicken tender fritters, (2) cases of (48) 4 ounce vanilla ice cream cups, 5 pound case of chicken breast tenders, 10 pound case of (80 count) pork franks, (2) 5 pound bags of smile fry potatoes, and 32 hamburger patties were not frozen solid. The CDM confirmed the thermometer reading in the walk-in freezer was 30 degrees and confirmed the food items were not frozen solid, were available for resident use, and should have been discarded. During an interview on 9/28/2025 at 2:55 PM, the Infection Preventionist (IP) stated no residents in the facility had shown any signs of foodborne illness. During an interview and observation of medication cart 3 on 9/29/2025 at 9:00 AM, revealed a 32-ounce carton of nutritional supplement 1/2 full with an expiration date of 7/4/2025. Licensed Practical Nurse (LPN) A confirmed the nutritional supplement was expired and available for resident use.

Based on medical record review, observation, and interview, the facility failed to ensure 1 resident (Resident #19) was treated with dignity during feeding assistance of 7 residents observed for dining.The findings include:Review of the facility's policy titled, Resident Rights, undated, revealed .You have the right to be treated with dignity and respect in a manner that promotes or enhances your quality of life .Resident #19 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Spastic Quadriplegic Cerebral Palsy, and Dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #19 was dependent on staff for eating. Review of the comprehensive care plan for Resident #19 revised 6/30/2025, revealed .ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] cerebral palsy, parkinson's disease .Eating .Requires total assistance to eat .During an observation on 9/28/2025 at 12:47 PM, Certified Nursing Assistant (CNA) B was standing over Resident #19 assisting the resident with the lunch meal.During an interview on 9/28/2025 at 12:56 PM, the Director of Nursing (DON) confirmed CNA B failed to promote dignity for Resident #19 when the CNA stood over the resident while assisting the resident with the lunch meal.

Based on review of facility policy, review of medical record, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) after the resident was admitted to the facility with a mental health diagnosis for 1 resident (Resident #11) of 8 residents reviewed for PASRR. The findings include:Review of the facility's policy titled, PASRR Policy and Procedure Program, undated, revealed .To ensure compliance with federal and state regulations regarding the .PASRR process for individuals seeking admission .particularly those with serious mental illness (SMI), Intellectual disability (ID), or related conditions (RC) .policy applies to all admissions to the SNF [Skilled Nursing Facility] .Resident Review .conducted when there is a .change in the resident's condition .may trigger a new PASRR evaluation.Review of a PASRR Level I Screen for Resident #11 dated 3/3/2020 (submitted prior to admission to the facility), revealed the resident had .Anxiety Disorder .Psychotropic Medications .Buspar 10 MG [milligram] daily for Anxiety Disorder . Further review revealed Resident #11's PASRR did not include diagnoses of PTSD (Post-Traumatic Stress Disorder) and Schizoaffective Disorder.Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Schizoaffective Disorder, Anxiety Disorder, and PTSD.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #11 had active diagnoses of Anxiety Disorder, Schizophrenia, and PTSD.Review of the comprehensive care plan for Resident #11 revised 9/26/2025, revealed .Antidepressant medication use r/t [related to] Depression, Schizoaffective disorder .Antipsychotic medication use r/t Schizophrenia .At risk for Re-Traumatization r/t Post-Traumatic Stress Disorder (PTSD) r/t gang violence .Potential for mood problem r/t dx [diagnosis] depression, anxiety, schizoaffective disorder .During an interview on 9/30/2025 at 9:46 AM, the Admissions/Licensed Practical Nurse (LPN) Nurse Case Manager confirmed Resident #19's PASSR had not been resubmitted to include PTSD and Schizoaffective Disorder until 9/29/2025. During a record review and interview on 9/30/2025 at 9:51 AM, the Director of Nursing (DON) confirmed a new PASRR had not been submitted to include diagnoses of PTSD and Schizoaffective Disorder after the resident was admitted to the facility on [DATE].

Based on review of the facility policy, record review, observations and interviews, the facility failed to develop a comprehensive person-centered care plan for 1 resident (Resident #82) of 19 residents reviewed for care plans.The findings include:Review of the facility policy titled, Comprehensive Person-Centered Care Planning, dated 12/2023, revealed .facility.shall develop a comprehensive person-centered care plan for each resident that includes.information necessary to properly care for each resident.Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region Stage 4, Chronic Hepatitis C, and Herpes Viral Infection of Urogenital System. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #82 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a pressure ulcer and viral hepatitis.Review of the Physician Orders dated 9/26/2025 for Resident #82 revealed the resident had Transmission-Based Precautions for Wound Organism. Further review revealed an order dated 9/27/2025 to paint lesions to inner vulva (external female genitialia) with betadine daily.Review of the comprehensive care plan for Resident #82 dated 7/15/2025, revealed the resident had pressure ulcers with enhanced barrier precautions. Further review revealed the resident did not have a care plan for transmission-based precautions.During an observation on 9/28/2025 at 10:45 AM, revealed transmission-based precautions were in place with a sign and appropriate personal protective equipment (PPE) located on Resident #82's door.During an interview on 9/30/2025 at 11:05 AM, the Infection Preventionist (IP) confirmed Resident #82 was on transmission-based precautions due to the resident's wounds had copious (large) amounts of drainage and a diagnosis of Viral Hepatitis C.During an interview on 9/30/2025 at 4:54 PM, the Director of Nursing (DON) confirmed Resident #82's care plan had not been developed to include transmission-based precautions.

Based on review of the facility policy, review of manufacturer guidelines, medical record review, observations, and interviews the facility failed to ensure insulin medication was labeled appropriately to include an open date for 2 residents (Resident #46 and Resident #23) and failed to ensure eye medication was labeled appropriately to include an open date for 1 resident (Resident #67) of 3 residents reviewed for medication administration on 1 medication cart of 2 medication carts observed.The findings include:Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, revealed .The nursing staff is responsible for maintaining medication storage .in a .safe .manner .Medications are stored .and are labeled accordingly .Review of the manufacturer guidelines, undated, revealed .HOW SUPPLIED/STORAGE AND HANDLING .Storage Conditions for TRESIBA FlexTouch [Degludec] [medication used to treat diabetes] .In-use (opened) .Room Temperature .56 days .Storage conditions for .NovoLog [Insulin Aspart] [medication used to treat diabetes] .In-use (opened) .28 days .Review of the manufacturer guidelines, undated, revealed .Storage and Handling .Xalatan [Latanoprost] [medication used to lower elevated eye pressure] .Once a bottle is opened for use, it may be stored at room temperature .for 6 weeks .Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Pain Syndrome, and Hypertension.Review of a Physician's Order for Resident #46 dated 7/4/2025, revealed .Tresiba FlexTouch .100 UNIT/ML [milliliter] .(Insulin Degludec) .Inject 15 unit .at bedtime .Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Hypertension.Review of a Physician's Order for Resident #23 dated 9/15/2025, revealed .Insulin Aspart .Pen-Injector 100 UNIT/ML .Inject .sliding scale [a method for administering insulin that relies on pre-meal blood sugar measurements] before meals and at bedtime .Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Unspecified Glaucoma, Major Depressive Disorder, and Hypertension.Review of a Physician's Order for Resident #67 dated 9/3/2025, revealed .Latanoprost Opthalmic Solution .Instill 1 drop in both eyes at bedtime .During an observation of medication cart 3 on 9/29/2025 at 8:29 AM, revealed an opened Degledec Insulin 100 UNIT/ML Flexpen at room temperature for Resident #46. The insulin was undated and had a label which read to discard after 56 days. Further observation revealed an opened Novolog Insulin 100 UNIT/ML Flexpen at room temperature for Resident #23. The insulin was undated and had a label which read to discard after 28 days. Continued observation revealed an opened 2.5 ml bottle of Latanoprost Opthalmic solution for Resident #67. The bottle was undated and had a label which read to discard after 42 days.During an interview on 9/29/2025 at 8:58 AM, Licensed Practical Nurse A confirmed medications were not stored properly for Residents #46, #23, and #67.During an interview on 9/30/2025 at 4:41 PM, the Director of Nursing confirmed medications were not stored properly for Residents #46, #23, and #67.

Based on review of the facility policy, medical record review, observations and interviews the facility failed to ensure staff followed infection control guidelines during wound care for 1 resident (Resident #44) of 3 residents reviewed for wounds. The findings include:Review of the undated facility policy titled, Wound Care, revealed .Put on exam glove. remove dressing .Pull glove over dressing and discard.sanitize hands.put on gloves .Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, and Hypertension. Review of the Physician's Orders for Resident #44 dated 4/26/2025, revealed .cleanse sacrum with normal saline, pat dry, apply calcium alginate and collagen particles to wound bed and cover with foam dressing three times per week and as needed.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 scored 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment.Review of the comprehensive care plan dated 9/4/2025, revealed .hospice services .potential for further pressure ulcer development.stage 4 pressure ulcer . During an observation on 9/30/2025 at 8:55 AM, in Resident #44's room, the Wound Care Nurse donned gloves and gown, removed a soiled dressing, did not change gloves or sanitize the hands, and cleansed the resident's wounds. During an interview on 9/30/2025 at 9:10 AM, the Wound Care Nurse confirmed he failed to remove gloves or sanitize the hands after he removed a soiled dressing and proceeded to cleanse Resident #44's wound. During an interview on 9/30/2025 at 4:48 PM, the Director of Nursing (DON) confirmed Wound Care Nurse failed to follow infection control practices when he provided wound care to Resident #44.

Based on facility policy review, medical record review, facility documentation review, observation, and interview, the facility failed to prevent and protect 1 resident (Resident #3) from abuse of 3 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 8/30/2022, showed .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 .Abuse is defined as willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Cerebellar Ataxia, Hypertension, and Chronic Kidney Disease. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Brief Interview of Mental Status (BIMS) score was 14 indicating the resident was cognitively intact, had no mood indicators, and no behaviors were documented. The resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and total assistance with bathing. Resident able to feed self. Review of Resident #2's care plan dated 2/17/2020 showed resident had behavior of refusal of care and care resistance interventions in place. Interventions medications as ordered, monitor behaviors and side effects of medications, and psych services as indicated. Resident #3 was admitted to the facility on [DATE] with diagnoses including Diffuse Traumatic Brain Injury, Muscle Weakness, Anxiety, and Hemiplegia and Hemiparesis following Cerebral Infarction. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Brief Interview of Mental Status (BIMS) score was 12 indicating the resident had moderate cognitive impairment, had no mood indicators, and no behaviors documented. The resident required limited assistance of 1 staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and extensive assistance with bathing. Resident received antianxiety medication routinely. Review of Resident #3's care plan dated 3/17/2022 showed resident had behavior of sexual inappropriate with the staff, interventions in place. Interventions medication Depo injection (hormone progestin used to decrease sexual behavior) as ordered, set boundaries for resident, monitor behaviors and side effects of medications, Psych services as indicated. Review of a nurse progress note for Resident #3 dated 12/25/2022 staff noted resident was standing in front of roommate hitting roommate, residents separated no apparent injury noted, when asked why he hit his roommate resident stated he had my hat. Notified Nurse Practitioner for order to send resident out to hospital for evaluation. Noted resident had a split lip, resident stated roommate hit him in the face during the altercation, he denied any pain. Review of the facility's investigation dated 12/25/2022 showed Resident #3 attempted to hit Resident #2 because he wanted his hat. Resident #2 stated .I was wearing my hat and Resident #3 grabbed it and hit me in the chest. I punched him in the leg and in the mouth, he started it . Certified Nursing Assistant (CNA) stated Resident #3 was standing over Resident #2 and swinging at him. Resident #2 was swinging back at him. The CNA separated the 2 residents immediately. Review of a nurse progress note for Resident #3 dated 12/25/2022 showed resident was transported by EMS (Emergency Medical Service) to the hospital for evaluation. Review of a hospital emergency room physician progress note dated 12/25/2022 for Resident #3 showed .Patient was punched in the face presented with facial pain, CT [Computerized Tomography] of the maxillofacial bones is negative for any acute fractures. There was no loss of consciousness, and the mechanism of the trauma was minor, no concern for any other underlying injuries. Patient has a completely nonfocal neurological exam and stable vital signs. Stable for discharge . During an interview on 1/13/2023 at 2:00 PM, Resident #2 revealed my roommate was taking my hat away and he would not give it back, and he was standing over me swinging his arm, he punched me in the chest, so I punched him in the face. During an interview on 2/13/2023 at 2:36 PM, Resident #3 denied he had been hit by another resident. He did not recall the altercation. During observation on 2/13/2023 at 10:00 AM, showed Resident #2 in his room on the first unit, no behaviors noted. During an observation on 2/13/2023 at 10:10 AM, showed Resident #3 in his room on the second unit of the facility, no behaviors noted. During an interview on 2/14/2023 at 1:30 PM, the Administrator confirmed, during the altercation between Resident #2 and Resident #3, Resident #3 had sustained a minor injury to his lip.

Based on review of the Facility Assessment, review of facility's daily staffing sheets, review of facility shower schedules, medical record review, and interview, the facility failed to provide adequate staffing on the weekends to meet the needs of residents in the facility for 2 months (May and June 2022), which had the potential to affect all residents in the facility. The findings include: Review of the Facility Assessment updated 4/25/2022, showed the average daily census was 60. Licensed nurses and Certified Nurse aides (CNA) providing direct care total number needed or average range correlates to census number; staff will be assigned to meet needs of all residents. Review of the facility assignment sheets dated 5/1/2022-5/31/2022 and 6/1/2022-6/27/2022 showed the facility had fewer CNA's working on the weekends. Review of the facility's shower schedule revised 6/15/2022, showed Resident #29 was to receive a shower on Wednesday and Saturday on dayshift (7:00 AM- 3:00 PM). Review of Resident #29's shower documentation dated 6/1/2022-6/27/2022, showed Resident #29 had received a shower on 6/1/2022 (a Wednesday), 6/15/2022 (a Wednesday), and 6/22/2022 (a Wednesday). There was no documentation Resident #29 had received a shower on 6/4/2022, 6/11/2022, 6/18/2022, or on 6/25/2022 (all Saturdays). She had missed 4 showers for the month of June 2022. During an interview on 6/26/2022 at 8:45 AM, CNA #1 stated there was more staff through the week, .weekends are hectic . During an interview on 6/26/2022 at 9:00 AM, CNA #3 stated there was usually only 3 CNAs scheduled on the weekends and CNAs must keep a faster pace to get the residents cared for. She stated staffing was better through the week. During the resident council meeting on 6/27/2022 at 10:00 AM, 3 of the sampled residents present stated the facility needed more CNAs on the weekends, and the call lights took longer to get answered on the weekends than through the week. The residents stated showers did not always get done on the weekends. During an interview on 6/27/2022 at 8:30 AM, CNA #4 stated the weekends were rough, usually only 3 CNAs were scheduled. She stated through the week was a lot better. During an interview on 6/27/2022 at 8:50 AM, CNA #5 stated staffing was better through the week than on the weekend. During an interview on 6/27/2022 at 9:05 AM, CNA #2 stated staffing was not as good on the weekends as through the week. During an interview on 6/27/2022 at 1:20 PM, Resident #160 stated .yesterday was my first time getting a shower [admitted [DATE]] . He stated he had asked for a shower on 6/26/2022 and had been told it wasn't his scheduled day for a shower. He stated a male CNA had agreed to assist him with a shower later that night on the evening shift. The resident stated he had wanted a shower prior to 6/26/2022 .everyone tells you something different .some say we are short of help . During an interview on 6/28/2022 at 8:53 AM, CNA #6 stated she was sometimes unable to complete her assigned showers due to being .shorthanded [short of staff] . During an interview on 6/28/2022 at 5:48 PM, the staffing sheets were reviewed with the Administrator. He stated the facility went through a rough period trying to hire new staff. The Administrator confirmed CNA staffing was based on the average census range per the facility assessment. The Administrator confirmed the facility had 4-5 CNAs scheduled during the week and should also have 4-5 CNAs scheduled on the weekends. During an interview on 6/27/2022 at 1:20 PM, Resident #160 stated .yesterday was my first time getting a shower [admitted [DATE]] . He stated he had asked for a shower on 6/26/2022 and had been told it wasn't his scheduled day for a shower. He stated a male CNA had agreed to assist him with a shower later that night on the evening shift. The resident stated he had wanted a shower prior to 6/26/2022 .everyone tells you something different .some say we are short of help . During an interview on 6/28/2022 at 8:53 AM, CNA #6 stated she is sometimes unable to complete her assigned showers due to being .shorthanded [short of staff] . During an interview on 6/28/2022 at 5:48 PM, the staffing sheets were reviewed with the Administrator. He stated we went through a rough spell trying to get new hires, 2 weeks ago switched ads and got some new applications come in. The administrator confirmed CNA staffing is based on the average census range per the facility assessment. The Administrator confirmed the facility had 4-5 CNAs scheduled during the week and should have 4-5 should be scheduled on weekends.

Based on facility policy review, observation, and interview, the facility failed to properly store frozen foods in 1 of 1 freezer, failed to date 3 containers of dried foods in the kitchen area, and failed to maintain proper temperatures in 2 of 2 nourishment refrigerators, potentially affecting 58 of 60 residents in the facility. The findings include: Review of the facility policy titled, Food Storage-Dry Goods, dated 10/2019, showed .The Dining Services Director or designee ensures .the storage .date marked as appropriate . Review of the facility policy titled, Food Storage .Cold, dated 10/2019, showed .all food items are stored properly .arranged in a manner to prevent cross contamination . During an observation of the walk-in freezer on 6/26/2022 at 9:20 AM, with the Regional Director of Dietary Services revealed the following: 1. A 2-pound bag of peas, spilled in the box and open to air with freezer burn (covered in ice crystals). 2. An 8-pound ribeye open to air with freezer burn. 3. 15 4-ounce chicken breasts open to air with freezer burn. 4. 14 fish fillets open to air with freezer burn. 5. 5 8-ounce containers of cream cheese with an expiration date of 5/25/2022. 6. A 6-pound ham open to air with freezer burn. 7. A 2-pound ham open to air with freezer burn. 8. 40 donut holes open to air. 9. 14 chicken tenders open to air. 10. 32 omelettes open to air. 11. 14 chicken patties open to air. During an observation on 6/26/2022 at 9:45 AM, with the Regional Director of Dietary Services of dried storage revealed the following in the kitchen area: 1. 2 quarts of dried cereal undated. 2. 1/2 quart of dried cereal undated. 3. 4 quarts of dried cereal undated. During an interview on 6/26/2022 at 9:55 AM, the Regional Director of Dietary Services confirmed the facility failed to properly store frozen and dried foods and the items were available for resident consumption. During an observation of the nourishment refrigerators on 6/28/2022 at 2:17 PM, with the Culinary Services Manager, there was a temperature log posted on front of unit 2's refrigerator dated 6/1/2022-6/28/2022. Temperatures on 6/1, 6/2, 6/15, 6/16, 6/19, 6/22, and 6/24/2022 were documented at 42 degrees (maximum temperature should be 41 degrees) and no temperature was checked on 6/28/2022. Observation of unit 1's refrigerator temperature log dated 6/1/2022-6/28/2022 showed on 6/8, 6/9, 6/12, 6/13, 6/21, and 6/22/2022 temperatures were documented at 42 degrees and no temperature was checked on 6/27 and 6/28/2022. During an interview on 6/28/2022 at 2:30 PM, the Culinary Services Manager confirmed the nourishment refrigerator temperature log on both nourishment refrigerators had documented temperatures above 41 degrees and no temperature was checked on 6/28/2022 for unit 2 and on 6/27 and 6/28/2022 for unit 1.

Based on review of the facility policy, medical record review, observation, and interview, the facility failed to develop a comprehensive care plan to include a urinary catheter for 1 resident (Resident #12), to include Activities of Daily Living (ADL) for bathing for 4 residents (Residents #14, #29, #52, and #210), and to include use of [CONDITION(S)] medications for 1 resident (Resident #35) of 20 residents reviewed for care plans. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 1/2/2020, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment . Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated the resident was cognitively intact. The resident required extensive assistance of 2 staff for ADL care needs and had an indwelling catheter. Review of a Physician's Order dated 4/8/2022, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #12's care plan showed no documentation of an indwelling catheter. During an observation on 6/26/2022 at 8:30 AM, showed the resident lying in bed on the left side with an indwelling catheter present. During an interview on 6/27/2022 at 2:42 PM, the Director of Nursing (DON) confirmed there had not been a comprehensive care plan developed to address the use of an indwelling catheter for Resident #12. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's comprehensive care plan dated 10/15/2021, showed the resident had an Activities of Daily Living (ADL) self-care performance deficit with interventions which included the need for assistance with oral care. There was no documentation of the resident's need for assistance with bathing/showers. Review of Resident #14's admission MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 15, which indicated she was cognitively intact. She required physical help with one staff member assistance for part of her bathing. Review of Resident #14's quarterly MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 15 and she was totally dependent with one staff member assistance for bathing. During an interview on 6/27/2022 at 3:03 PM, the DON confirmed Resident #14 required assistance with bathing and her comprehensive care plan did not address her need for assistance with bathing. Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's admission MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 6, which indicated she had severe cognitive impairment. She was dependent with one staff member assistance for bathing. Review of Resident #29's comprehensive care plan dated 4/22/2022, showed a care plan for ADL needs to include her need for assistance with bathing had not been developed. During an interview on 6/27/2022 at 2:58 PM, the DON confirmed Resident #29 did require assistance with bathing and there had not been a comprehensive care plan developed to address her need for assistance with ADL's which would include her need for assistance with bathing. Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's admission MDS assessment dated [DATE], showed a BIMS assessment score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance of one staff member for personal hygiene and had not bathed in the previous 7 days. Review of Resident #52's comprehensive care plan dated 5/29/2022, showed the resident had an ADL self-care performance deficit. There were no interventions listed on the care plan for ADL needs which would include her need for bathing assistance. During an interview on 6/27/2022 at 3:07 PM, the DON confirmed Resident #52 required assistance with bathing and her ADL care plan was incomplete. She confirmed a care plan had not been developed for Resident #52 to include the need for assistance with ADL's, which would include her need for assistance with bathing. Resident #210 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #210's admission/5-day MDS assessment dated [DATE], showed a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with ADL care needs, and was frequently incontinent of bowel and bladder. Review of a care plan for Resident #210 dated 5/26/2022, showed no documentation a comprehensive care plan had been developed for Resident #210. During an interview on 6/27/2022 at 2:42 PM, the DON confirmed a comprehensive care plan had not been developed for Resident #210. Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's Order Summary Report showed the resident had a physician's order dated 5/18/2022 for [MEDICATION(S)] (a [CONDITION(S)] medication used to treat anxiety) 10 mg (milligrams) to be administered twice daily, and a physician's order dated 5/18/2022 for [MEDICATION(S)] (a [CONDITION(S)] medication used to treat depression) 100 mg to be administered once daily. Review of Resident #35's significant change MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 5, which indicated the resident had severe cognitive impairment. The resident had received an antianxiety medication and an antidepressant medication daily. Review of Resident #35's care plan showed no documentation a care plan had been developed for the use of [CONDITION(S)] medications which would include interventions for the monitoring of side effects of [CONDITION(S)] medications and behaviors. During an interview on 6/28/2022 at 1:59 PM, the Special Projects Nurse (SPN) confirmed Resident #35 was receiving [CONDITION(S)] medications and a care plan had not been developed to address the use of [CONDITION(S)] medication which would include interventions to monitor for side effects of medication and behaviors.

Based on facility policy review, medical record review, facility shower schedule review, and interview, the facility failed to provide scheduled showers for 4 residents (Residents #14, #29, #52, and #160) of 10 residents reviewed for showers. The findings include: Review of the facility policy titled, Bathing a Resident, dated 1/2/2020, showed .It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues . Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated the resident was cognitively intact. She was totally dependent with one staff member assistance for bathing. Review of the facility's shower schedule revised 6/15/2022, showed Resident #14 was to receive a shower on 2nd shift (3:00 PM- 11:00 PM) on Tuesdays and Fridays. Review of Resident #14's shower documentation dated 6/1/2022-6/27/2022, showed the resident had received a shower on 6/23/2022 (Thursday). No other showers were documented for the time period. She did not receive showers on her scheduled shower days of 6/3/2022, 6/7/2022, 6/10/2022, 6/14/2022, 6/17/2022, and 6/21/2022 (6 missed showers). During an interview on 6/26/2022 at 9:52 AM, Resident #14 stated she went for about 3 weeks without a shower. She stated she would like to have a shower more frequently. Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's admission MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 6, which indicated she had severe cognitive impairment. She was dependent with one staff member assistance for bathing. Review of the facility's shower schedule revised 6/15/2022, showed Resident #29 was to receive a shower on Wednesday and Saturday on dayshift (7:00 AM- 3:00 PM). Review of Resident #29's shower documentation dated 6/1/2022-6/27/2022, showed Resident #29 had received a shower on 6/1/2022 (a Wednesday) , 6/15/2022 (a Wednesday), and 6/22/2022 (a Wednesday). There was no documentation Resident #29 had received a shower on 6/4/2022, 6/11/2022, 6/18/2022, or on 6/25/2022 (all Saturdays). She had missed 4 showers for the period. During an interview on 6/26/2022 at 9:50 AM, Resident #29 stated her shower schedule was for Wednesdays and Saturdays. She stated she did receive showers on Wednesdays, but not on Saturdays. She stated she would like more than one shower per week. Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's admission MDS assessment dated [DATE], showed a BIMS assessment score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance of one staff member for personal hygiene and had not bathed in the previous 7 days. Review of the facility's shower schedule revised 6/15/2022, showed Resident #52 was to receive a shower on Mondays and Thursdays on 2nd shift. Review of Resident #52's shower documentation dated 5/25/2022-6/27/2022, showed Resident #52 had received one shower on 6/23/2022 (Thursday). She had missed 9 showers. During an interview on 6/26/2022 at 9:48 AM, Resident #52 stated she had only had one shower since she was admitted on [DATE] and .would like to have a shower at least once a week . Resident #160 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #160's admission MDS assessment dated [DATE], showed the resident had a BIMS assessment score of 15, which indicated the resident was cognitively intact. Review of the facility's shower schedule revised 6/15/2022, showed Resident #160 was to receive a shower on Mondays and Thursdays on 2nd shift. Review of Resident #160's shower documentation dated 6/16/2022-6/27/2022, showed no documentation Resident #160 had received a shower. During an interview on 06/27/2022 at 1:20 PM, Resident #160 stated .yesterday was my first time getting a shower . He stated he had asked for a shower on 6/26/2022 and had been told it wasn't his scheduled day for a shower. He stated a male Certified Nursing Assistant (CNA) had agreed to assist him with a shower later that night on the evening shift. The resident stated he had wanted a shower prior to 6/26/2022 .everyone tells you something different .some say we are short of help . During an interview on 6/27/2022 at 1:15 PM, CNA #2 stated she was assigned showers when the shower aide was not working. She stated she had been able to get her assigned showers done .most of the time . She stated she was able to get her showers completed for today because there were 5 CNA's working. During an interview on 6/28/2022 at 8:53 AM, CNA #6 stated she was sometimes unable to complete her assigned showers due to being .shorthanded [short of staff] . During an interview on 6/28/2022 at 1:59 PM, the Special Projects Nurse (SPN) confirmed Resident #14 was scheduled to receive a shower on Tuesdays and Fridays on the 2nd shift. She confirmed Resident #14 was provided one shower from 6/1/2022-6/27/2022 and had missed 6 showers. The SPN confirmed Resident #29 was scheduled to receive showers on Wednesdays and Saturdays on the 1st shift. She confirmed Resident #29 had not received a shower on Saturday's from 6/1/2022-6/27/2022 and confirmed she had missed 4 showers. The SPN confirmed Resident #52 was scheduled to receive showers on Mondays and Thursdays on the 2nd shift. She confirmed from the resident's admitted on 5/25/2022 through 6/27/2022, Resident #52 had missed 9 showers. The SPN confirmed Resident #160 was scheduled to receive a shower on Mondays and Thursdays on the 2nd shift. She confirmed from the resident's admitted on 6/16/2022 through 6/27/2022, Resident #160 had received one shower and had missed 2 showers. She confirmed the facility had not provided showers per the resident's shower schedules.

Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a comprehensive resident admission assessment within 14 calendar days after admission for 1 resident (Resident #1) of 20 residents reviewed. The findings include: Review of the RAI Manual Admission Version 3.0 dated 10/2019, showed the admission assessment can be no more than 14 days from the date of admission or reentry, whichever is later. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed the assessment was not completed until 1/24/2022, 4 days late. During an interview on 6/28/2022 at 9:23 AM, the Special Project Nurse confirmed the admission assessment had been completed late, more than 14 days after the resident was admitted to the facility.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a baseline care plan to include the use of [CONDITION(S)] medications for 1 resident (Resident #160) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, Baseline Care Plan, revised 3/22/2022, showed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will .Include the minimum healthcare information necessary to properly care for a resident .Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .The admitting nurse .shall gather information from the admission .physician orders .Interventions shall be initiated that address the resident's current needs including .Any identified needs for supervision, behavioral interventions . Resident #160 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #160's Order Summary Report showed an order dated 6/16/2022, for [MEDICATION(S)] (a [CONDITION(S)] medication used for anxiety) 0.5 mg (milligrams) to be administered every 8 hours as needed for anxiety. Review of Resident #160's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 6/17/2022, showed no documentation the resident had been care planned for the use of the [CONDITION(S)] medication with interventions to include the monitoring of side effects or behaviors. Review of Resident #160's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated the resident was cognitively intact. Observations of the resident on 6/26/2022 at 9:27 AM, 6/27/2022 at 1:20 PM, and 6/28/202 at 8:30 AM, showed the resident awake, talkative, and with no behaviors noted. During an interview on 6/27/2022 at 2:51 PM, the Director of Nursing (DON) confirmed the resident had a [CONDITION(S)] medication ordered on admission and the baseline care plan did not include the use of the [MEDICATION(S)] or the need for side effect monitoring and behavior monitoring for the use of the [CONDITION(S)] medication.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for wound treatment for 1 resident (Resident #10) of 4 residents reviewed for wounds. The findings include: Review of the facility policy titled, Wound Treatment Management, revised 3/24/2022, showed .Wound treatment will be provided in accordance to physician orders, including .type of dressing, and frequency of dressing change .The facility will follow specific physician orders for providing wound care . Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 6/4/2021, showed .House NP [Nurse Practitioner] Wound Care to eval [evaluate] and treat . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #10 had severe cognitive impairment. The resident required total assistance of 2 staff members for bed mobility, toileting, and had impaired range of motion to both legs. Review of Resident #10's Weekly Skin Review dated 5/25/2022, 6/1/2022, 6/8/2022- and 6/15/2022, showed the resident did not have any skin breakdown issues identified. Review of a physician order dated 6/22/2022, revealed apply [MEDICATION(S)] (antimicrobial skin cleanser) to left upper leg/outer thigh and leave open to air. Review of the comprehensive care plan initiated 6/22/2022, revealed Resident #10 had a wound to his outer thigh with interventions to include: measure wound every week and treatment as ordered . Review of a Wound Care Progress Note dated 6/23/2022, revealed the Wound Care Nurse Practitioner documented .Seeing the resident today to assess a wound .history of vascular disease .contracture .ulcer to the left thigh measuring 6.8 centimeters [cm] x 4.8 cm .necrotic [dead] tissue .no drainage .[MEDICATION(S)] daily .right inner leg .blanchable redness .foam protective dressing . The progress note documented the resident had vascular/venous wounds to the left upper thigh and the right outer leg. Review of the medical record showed there was no documentation a physician's order was written for the foam protective dressing to the right inner leg as documented in the Wound Care Nurse Practitioner's wound care progress note dated 6/23/2022. Review of the Order Summary Report dated 6/26/2022, showed .heel elevating cushion .while in bed .Nursing to ensure in place and properly positioned .every shift .heel protectors while in bed every shift .padded limb protection stockings: Nursing to ensure in place to bilateral shins/lower extremity to offload pressure when resident crosses limbs. May need to change position of protective stocking throughout shift to ensure proper placement. every shift for Skin integrity Monitor for placement . Observation of Resident #10 on 6/26/2022 at 9:08 AM, in his room, showed the resident lying in bed on his left side holding on to the side rail with his right arm. Observation showed no heel elevating cushions, heel protectors, or padded limb protection stockings in place. Review of a Weekly Wound Observation Tool dated 6/26/2022, showed .first observation of this wound .Yes [indicating skin issues identified] .Date of Onset .6/26/2022 .see wound nurse report . Review of a Progress Note (Wound Nurse Report) dated 6/26/2022, showed the nurse was called into Resident #10's room by a Certified Nursing Assistant (CNA) to assess Resident #10's skin. The report documented the following wounds were observed: 1. Right lateral side of the lower leg was open with 100% granulation (beefy red tissue) which measured 2.2 cm x 0.9 cm 2. The left side of the left lower leg had an open area which contained 30% slough (yellow or tan tissue in a wound) and 70% granulation which measured 4.0 cm x 1.5 cm 3. The right side of the left lower leg had a fluid filled blister which measured 4.0 cm x 1.7cm 4. Right inner lower leg had multiple superficial (surface) wounds which measured in total 11 cm x 3.5 cm 5. Right inner ankle wound with 100% granulation which measured 1.5 cm x 3.5 cm 6. Right outer ankle wound which measured 1 cm x 1.6 cm with no tissue description 7. Right inner side of foot wound which measured 2.2 cm x 0.9 cm with no tissue description 8. Right outer side of foot wound which measured 2 cm x 1.3 cm with no tissue description 9. Right heel blister with a darkened wound base which measured 2.5 cm x 4.9 cm 10. A wound to the bottom of the left heel which measured 2 cm x 2.5 cm with no tissue description 11. A wound to the back of the left heel which measured 2 cm x 3 cm with no tissue description 12. Left side of foot wound near the 5th toe which measured 0.7 cm x 1 cm with no tissue description 13. Left great toe wound with a darkened area which measured 0.7 cm x 0.5 cm 14. Left 2nd toe wound with a darkened area which measured 0.5 cm x 1.3 cm 15. Left 3rd toe wound with a darkened area which measured 0.4 cm x 0.7 cm 16. Left buttock reddened/blanchable which measured 4 cm x 3 cm There was no documentation of the wound to the left upper leg/outer thigh which was noted in the 6/23/2022 Wound Nurse Practitioner progress note. Review of Resident #10's physician orders dated 6/26/2022 showed the following treatment orders: 1. Bilateral heels: [MEDICATION(S)] daily cover with dry dressing daily 2. Cleanse open areas to left side of the left lower leg with normal saline and apply wound ointment. Cover with bordered gauze dressing and change daily 3. Left buttock bordered foam dressing to the reddened area daily 4. Left great, second, and third toes: [MEDICATION(S)] to the darkened areas twice daily 5. Left outer side of foot near the 5th toe cover with border gauze daily 6. Right inner ankle: Cleanse with normal saline and apply a bordered foam dressing daily 7. Right inner lower leg: Cover area with protective bordered foam dressing, change daily, and monitor for changes 8. Right outer ankle: Cover with foam bordered dressing daily Observation of Resident #10 on 6/27/2022 at 10:10 AM, in his room, showed the resident awake and lying on his back, covered with a sheet. Observation showed no heel elevating cushions, heel protectors, or padded limb protection stockings in place. Observation of Resident #10 on 6/28/2022 at 8:18 AM, in his room, showed the resident lying on his back covered with a sheet. Observation showed no heel elevating cushions or heel protectors in place. The padded limb protection stockings were in place on both lower legs but had slid down and were not in the proper position. Review of the Treatment Administration Record (TAR) dated 6/1/2022-6/28/2022, showed there was no documentation wound care had been provided to the left upper leg on 6/26/2022, 6/27/2022, or 6/28/2022. The was no documentation of a physician's order for a foam protective dressing to the right inner leg. During an interview on 6/28/2022 at 8:30 AM, the Wound Care Nurse stated she had received a text from the Wound Care Nurse Practitioner on 6/23/2022 at 4:03 PM regarding Resident #10's left upper thigh wound. She confirmed she had not assessed the wounds until 6/26/2022 (3 days later) when a CNA asked her to come assess the resident's skin. The Wound Care Nurse confirmed Resident #10 had multiple wounds at the time she assessed him on 6/26/2022. During an observation on 6/28/2022 at 10:04 AM of Resident #10's wounds with the Wound Care Nurse showed the following: 1. Upon entering the room, the heel elevating cushions, and heel protectors were not in place and were not in the room. The padded limb protection stockings were in place on both lower legs but had slid down and were not in the proper position. 2. A wound to the left upper thigh was covered with an undated border gauze dressing. The physician's order was to leave the wound open to air. The nurse removed the dressing and there was an oval shaped wound with a dark colored center. A small amount of yellow tinged drainage was noted on the dressing with no odor. 3. Bilateral heels had intact dark colored skin with no dressing covering the wounds and the physician's order was to cover the heels with a dry dressing. The nurse applied [MEDICATION(S)] but did not apply the physician ordered dressing. 4. The left lower leg had multiple scattered superficial open areas with no dressing in place. The nurse applied normal saline with wound ointment and left open to air. The physician's order was to cover the wounds with border gauze dressings. 5. The left great, second, and third toes had small dark intact areas. The nurse applied [MEDICATION(S)] and left the toes open to air as ordered by the physician. 6. The wound to the left outer foot near the 5th toe had no dressing in place and was a small dark intact area. The nurse applied [MEDICATION(S)] to the wound and left it open to air. The physician's order was to cover the wound with gauze and not to apply [MEDICATION(S)]. 7. The right lower inner and outer leg, which had not been previously documented in the wound care assessments, had a dressing in place dated 6/26/2022 with the Wound Care Nurse's initials. The wound care nurse removed a wrapped gauze dressing, and underneath the dressing was three 4 x 5 bordered gauze dressings on the inner side of the leg, placed directly against the resident's skin. There was a moderate amount of yellow tinged drainage observed on the dressings with no odor. Observation of the wounds showed the inner aspect of the leg had a large open wound with red beefy tissue. The outer aspect of the leg had an elongated skin tear with a small amount of bleeding noted. The wound care nurse cleansed the wounds with normal saline, applied four 4 x 5 bordered gauze dressings, and applied [MEDICATION(S)] to the skin tear on the outer aspect of the leg. The physician's order was for a bordered foam dressing to be applied daily to the inner aspect of the lower leg. Further observation after the wound care nurse had exited the room and during CNA repositioning of the resident, showed a small, reddened area to the left buttock with no dressing in place. The physician had ordered border foam dressing to be changed daily. Prior to exiting the room, the CNA's reapplied the Limb Protection Stocking but did not put apply the heel elevating cushions and heel protectors. During an interview on 6/28/2022 at 10:25 AM, the Wound Care Nurse confirmed she had wrapped the lower right leg with a gauze dressing on 6/26/2022 and placed her initials on the dressing. She also confirmed the wound dressing had not been changed as ordered and the incorrect dressing had been applied. During an interview on 6/28/2022 at 10:51 AM, the Wound Care Nurse Practitioner (NP) stated she was contacted by a nurse at the facility on 6/22/2022 and had been made aware the resident had a new wound to the upper thigh and a treatment was ordered. During her weekly scheduled visit to the facility on [DATE], she had been informed by the Director of Nursing (DON) to assess Resident #10's skin. The resident had blanching redness with no open wounds to the right lower inner leg (the resident's right lower extremity was contracted and the left leg would lay across the right leg applying pressure). The Wound Care NP gave a verbal order to the DON for the bordered foam dressing to be applied once daily. The NP confirmed the DON had not placed the order for the foam dressing in the electronic health record and the foam dressing was the most appropriate dressing to treat the wounds and relieve pressure. The NP confirmed an occlusive dressing such as the border gauze and gauze wrap could cause deterioration of the wounds to the right inner lower leg. During an observation and interview on 6/28/2022 at 11:00 AM with the Wound Care Nurse Practitioner in Resident #10's room, the Wound Care Nurse Practitioner removed the dressing to the left upper thigh wound and stated the wound now had drainage since she last observed it on 6/23/2022. The Wound Care Nurse Practitioner then removed the dressing from the right inner lower leg and stated the skin was intact upon her last observation on 6/23/2022 and the wound was now open. Record review of a physician's order dated 6/28/2022, showed the Wound Care Nurse Practitioner wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Care Nurse Practitioner ordered to apply Santyl to the necrotic area and cover the left upper thigh area with a dry dressing daily. During an interview on 6/28/2022 at 3:19 PM, the DON confirmed if the incorrect dressing was applied it could cause the wound to deteriorate.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for an oral nutritional supplement for weight loss for 1 resident (Resident #37) of 3 residents reviewed for weight loss. The findings include: Review of the facility policy titled, Nutritional Management, dated 1/2/2020, showed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status .Interventions will .address the specific needs of the resident . Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's facility documented weights showed on 5/5/2022 the resident was 86 pounds, and on 6/15/2022 was 84 pounds, indicating a weight loss of 2 pounds or 2.33 % (percent) loss. Review of a Certified Dietary Manager Progress Note dated 5/23/2022, showed .increase fortified shakes to TID [three times a day] to provided [provide] additional 725 .cal [calories] and 26 gm [gram] protein total . Review of Resident #37's active physician orders showed, .Fortified Shake three times a day for weight loss .with all meals .Order Date 05/23/2022 . Review of Resident #37's meal tray card showed the resident received a nutritional treat (fortified shake) at lunch and supper. During an observation on 6/27/2022 at 8:10 AM, Resident #37 did not have a fortified shake on her breakfast tray. During an interview on 6/27/2022 at 8:15 AM, Certified Nurse Assistant (CNA) #1 stated she cared for Resident #37 routinely and she was not aware the resident had an order to receive a shake at breakfast; it is never on her tray. During an observation on 6/28/2022 8:15 AM, Resident #37 did not have a fortified shake on her breakfast tray. During an interview on 6/28/2022 at 8:20 AM, the Director of Nursing confirmed Resident #37 did not have a fortified shake on the breakfast tray. During an interview on 6/28/2022 at 9:55 AM, the Special Projects Nurse confirmed the resident had a physician's order for shakes three times a day dated 5/23/2022. During an interview on 6/28/2022 at 2:35 PM, the Culinary Services Manager stated he had not been made aware Resident #37 had an order to increase the fortified shakes to three times a day. He confirmed the resident did not receive the fortified shakes at breakfast.

Based on facility policy review, medical record review, pharmacy recommendation review, and interview, the facility failed to act timely on a pharmacy recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Medication Regimen Review, dated 5/2022, showed .The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly .Recommendations are acted upon and documented by the facility staff . Review of the facility policy titled, Consultant Pharmacist Reports, dated 5/2022, showed .The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . Resident #8 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Hypertension, Major Depressive Disorder, Anxiety Disorder, and Chronic Pain. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. Resident #8 had received antianxiety and antidepressant medications daily. Review of Resident #8's comprehensive care plan dated 10/8/2019, showed the resident received antianxiety medications related to a diagnosis of Anxiety Disorder with interventions which included .Pharmacist to review medications per facility policy with consideration of gradual dose reduction . Review of a consultant pharmacist review dated 12/12/2021, showed the pharmacist recommended a gradual dose reduction of Resident #8's [MEDICATION(S)] (medication used to treat anxiety) to 7.5 mg (milligram) three times daily. The Nurse Practitioner (NP) had signed the recommendation and agreed with the reduction on 2/22/2022, 72 days later. During an interview on 6/28/2022 at 1:59 PM, the Special Projects Nurse (SPN) confirmed the facility had not acted upon the pharmacist's recommendation timely.

Based on facility policy review, medical record review, pharmacy recommendation review, and interview, the facility failed to provide a gradual dose reduction per pharmacist recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Consultant Pharmacist Reports, dated 5/2022, showed .The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . Resident #8 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Hypertension, Major Depressive Disorder, Anxiety Disorder, and Chronic Pain. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. Resident #8 had received antianxiety and antidepressant medications daily. Review of Resident #8's comprehensive care plan dated 10/8/2019, showed the resident received antianxiety medications related to a diagnosis of Anxiety Disorder with interventions which included .Pharmacist to review medications per facility policy with consideration of gradual dose reduction . Review of a consultant pharmacist review dated 12/12/2021, showed the pharmacist recommended a gradual dose reduction of Resident #8's [MEDICATION(S)] (a medication used to treat anxiety) from 10 mg (milligrams) three times per day to be decreased to 7.5 mg three times daily. The Nurse Practitioner (NP) had signed the recommendation and agreed with the reduction on 2/22/2022. Review of Resident #8's Order Summary Report (current orders) showed an order for .[MEDICATION(S)] .10 mg .three times daily . During an interview on 6/28/2022 at 1:59 PM, the Special Projects Nurse (SPN) confirmed the NP had agreed with the pharmacy recommendation on 2/22/2022 to decrease Resident #8's [MEDICATION(S)] from 10 mg to 7.5 mg three times daily. The SPN confirmed the resident's [MEDICATION(S)] had not been decreased to 7.5 mg and the facility had failed to provide the recommended gradual dose reduction.

Based on review of facility policy, medical record review and interview, the facility failed to notify the resident's representatives of changes in medical condition and room changes for 1 resident (Resident #1) of 6 residents reviewed. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Brief Interview for Mental Status dated 3/30/2021 revealed the resident was moderately cognitively impaired. Medical record review of a wound care assessment (not dated) revealed the resident developed a pressure ulcer on his right heel which was necrotic on 5/19/2021. Continued review revealed the physician ordered Multi-Vitamin to include Vitamin C and Zinc; [MEDICATION(S)] foods (super cereal); low air loss and alternating pressure mattress for bed; and positioning pillows. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's notes revealed no documentation the resident's family was notified of the pressure ulcer on the resident's right heel. Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record review of the weight log on March 31, 2021 revealed the resident's weight was 173.7 lbs. and the next weight obtained on 4/15/2021 was 158 lbs. Medical record review of the Nutritional Status Review dated 4/15/2021 revealed .Admission weight-173.7 lbs. BMI-22.9. Wt (weight) today was 158 lbs indicating - 15 lb weight loss since admission. Will request recheck of weight. Prescribed a cardiac diet. Intake has been good at 76 to 100% consumed at most meals served. Able to feed self with tray set up. Has natural teeth with no apparent difficultly chewing or swallowing .Receives [MEDICATION(S)] daily. Calculated needs=1875 to 2250 kcal (25-30 kcal/kg), 75 to 90 gm (1-1.2 gm/kg), 1 ml/kg fluid. Continue to monitor . Medical record review of nurse's notes revealed no documentation the family was notified of the resident's weight loss of 15.7 lbs on 4/15/2021. Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of nurse's notes revealed no documentation the family was notified of the need for a urinary catheter. Review of documentation provided by the facility revealed the resident changed rooms on 4/21/2021 and again on 4/26/2021. The facility is undergoing renovation and the room changes were necessary to continue the renovation. Review revealed no documentation the family was notified of the room changes. Interview with the Director of Nursing (DON) on 6/25/2021 at 11:00 AM by telephone confirmed the resident's family was not notified of the pressure ulcer on the resident's right heel; confirmed the resident's family was not notified of the resident's weight loss between 3/31/2021 and 4/15/2021; confirmed the family was not notified of the insertion of the urinary catheter by the urologist during a office visit; and confirmed the resident's family was not notified of the room changes due to renovation.

Based on facility policy review, medical record review, and interview, the facility failed to complete thorough and accurate weekly skin assessments for 1 resident (Resident #1) of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled, Wound Treatment Management, dated 9/2/2020, showed .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modification include .Lack of progression towards healing .Changes in the characteristics of the wound . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Braden scale for predicting pressure sore risk dated 9/8/2020, showed no sensory perception impairment, skin often moist, chair fast, mobility slightly limited, adequate nutrition, and potential problem with friction and sheer. Resident #1 scored 16, which indicated a risk for developing pressure ulcers. Medical record review of an admission note dated 9/8/2020 at 3:45 PM, showed .open area to right buttock .right buttock 0.5 cm (centimeters) x (by) 1.0 cm. wound care nurse notified of skin assessment . Medical record review of a treatment order dated 9/8/2020 at 5:24 PM, showed .Order Summary: Barrier cream to affected area(s) after each incontinent episode and PRN (as needed) for skin care . Medical record review of the Admitting Skin Observation dated 9/9/2020 at 3:45 PM, showed .HEAD TO TOE SKIN CHECKS .Site .Abdominal (ABD) Midline .Type .Surgical x (times) 3 . There was no documentation of an assessment of the open area to the right buttock. Medical record review of a Wound Care Progress note dated 9/9/2020, showed .DETAILED WOUND ASSESSMENT: Wound #1: Lower abdominal surgical site x (times) 3 . There was no documentation of an assessment of the wound on the right buttock. Medical record review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 had Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact, required staff assistance of 1 for bed mobility, assistance of 2 staff for transfer, assistance of 1 staff for dressing and toileting/personal hygiene, and the resident was incontinent of both bowel and bladder. Resident #1 required staff assistance of 1 for eating and was totally dependent on staff for bathing. The resident had no impairments on either side and the resident was at risk of developing pressure ulcers. Medical record review of a Weekly Skin Review dated 9/15/2020 at 3:45 PM, showed .surgical sites to abdomen post appendectomy (removal of appendix) . There was no documentation of an assessment of the right buttocks to include location or description of the open area or wound. Medical record review of a physicians order dated 9/15/2020, showed .Apply zinc to buttock and cover with border dsg (dressing) daily one time a day . Medical record review of a Wound Care Progress note dated 9/16/2020, showed .History of Present Illness .we are seeing for abdominal surgical incision aftercare and possible moisture-associated skin damage to the buttocks/coccyx .Denies .diarrhea .Wound #2 Coccyx moisture-associated skin damage with [DIAGNOSES REDACTED] and maceration. No induration, exudate, ecchymosis, or odor .Treatment: We will apply Triad (skin cream) or zinc barrier cream t.i.d (three times per day) and p.r.n. (as needed) soiling . This was the first documentation of a thorough wound assessment for the wound to the right buttocks. Medical record review of a Nurses Weekly Wound/Ulcer Observation note dated 9/16/2020 at 3:26 PM showed .Coccyx - MASD (moisture associated skin damage) .No drainage noted .No signs/Symptoms of infection noted. MD (medical doctor)/NP (nurse practitioner) has been notified of need of Tx (treatment) change based on assessment findings . Medical record review of a physicians order dated 9/16/2020, revealed .apply zinc barrier cream tid to coccyx/buttocks three times a day for wound care apply zinc barrier cream tid to coccyx/buttocks (R&L) (right and left) . During an interview with the Director of Nursing (DON) on 10/28/2020 at 2:05 PM, confirmed the nurse on admission completed the initial skin assessment and documented the findings in the admission note. The expectation was floor nurses would complete the weekly skin assessments. During an interview with Licensed Practical Nurse (LPN) #2 on 10/28/2020 at 3:00 PM, confirmed she admitted Resident #1 and documented the resident had a wound on her right buttock. LPN #2 stated .it didn't have any depth to it .the top layer of skin was gone .(Resident #1) had an open area .her skin was not intact . During a telephone interview with Wound Care Nurse Practitioner (WNP) #1 on 10/28/2020 at 3:35 PM, WNP #1 stated Resident #1 was seen on 9/9/2020 to treat abdominal incision wounds and a full body skin assessment was completed. WNP #1 did not identify an open wound to the buttocks. Resident #1 was seen for wound care on 9/16/2020 and was assessed as having moisture associated skin damage to the coccyx and zinc barrier cream was ordered to be applied 3 times a day. Phone interview with LPN #1 on 10/28/2020 at 5:40 PM, revealed LPN #1 completed weekly skin checks and LPN #1 did not always thoroughly and accurately mark the sections on the assessment form. During an interview with the DON on 10/28/2020 at 6:30 PM, confirmed the facility failed to complete accurate weekly skin assessments.

Based on facility policy review, observation, and interview the facility failed to store cooking/serving utensils in a sanitary manner, failed to properly air dry 6 pans of approximately 15 pans observed, and failed to ensure expired foods were not available for resident use potentially affecting 64 of 65 residents. The findings include: Review of the facility's policy Storage of Clean Utensils and Pots and Pans, undated, revealed .This facility will ensure safe washing .and storage of cooking and serving utensils and pots and pans .All cooking and serving utensils and pots and pans will be air dried before storage in a clean .rack or storage shelf . Review of the facility's policy Refrigerators and Freezers, undated, revealed .This facility will .observe food expiration guidelines .Expiration dates on unopened food will be observed and use by dates indicated once food is opened .Culinary Services Manager will be responsible for ensuring food items .are not expired or past perish dates . Observation and interview with the Cook on [DATE] at 8:45 AM, in the kitchen, revealed the following: * one 1 ounce ladle with dried debris on the scoop end * one 1 ounce ladle with holes with dried debris on the scoop end * 1 spatula with dried debris on the handle * 3 steel quarter pans stacked wet * 2 steel 4 inch half pans stacked wet * 1 steel deep half pan stored wet Interview with the Cook confirmed the cooking/serving utensils were stored dirty and the steel pans were stored wet. Further observation and interview with the Cook on [DATE] at 8:50 AM, in the kitchen, revealed a 1 pound (lb) 7 ounce (oz) package of hamburger buns with 5 hamburger buns left in the package with a used by date of [DATE]. Interview with the Cook, at the time of the observation, confirmed the hamburger buns had expired and were available for resident use. Observation and interview with the Cook on [DATE] at 9:30 AM, in the walk in cooler, revealed an unopened box of coffee creamer containing 400/ 0.375 fluid (Fl) oz coffee creamers with an expiration date of [DATE]. Interview with the Cook confirmed the unopened box of coffee creamer had expired and were available for resident use.

Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse, which resulted in Resident #1 leaving the facility, being given alcohol, and being sexually assaulted. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator was informed of the Immediate Jeopardy (IJ) on 5/7/18 at 11:00 AM, in his office. The IJ was effective from 2/25/18 through 2/27/18. The IJ was removed on 2/28/18. The facility implemented a corrective action plan and corrective actions were validated onsite by the surveyor on 5/7/18 and 5/8/18. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings included: Review of facility policy, Resident Elopement, dated 11/28/17 revealed .identify when a resident has left the premises or a safe area without authorization and/or any necessary supervision to do so . Review of facility policy, Abuse, dated 11/28/17 revealed .Verbal, sexual, physical and mental abuse .are strictly prohibited . Medical record review of Resident #1;s Pre-Admission Screening and Resident Review (PASRR) document dated 7/26/17 revealed .This Level 1 shows her (Resident #1) to have suspected [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, alcohol and cocaine use disorder with most recent substance use in the past 15-30 days and dementia/neurocognitive disorder presenting with significant difficulty (with) communication, ambulating and/or completing routine motor tasks, recognizing familiar people or familiar objects, and has short/long term memory impairment. [MEDICAL CONDITION] medications have been prescribed. Currently or within the past 30 days, (resident) has had serious difficulty interacting with others, she has made substantial errors with tasks and she has experienced a life disruption due to mental health symptoms. (Resident) received mental health crisis services in the past 2-6 months and history of suicide attempt or gestures in the past 25 months - (to) 5 years and suicide attempt greater than 5 years ago . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan, dated 11/8/17, revealed the resident was at risk for elopement due to impaired safety awareness and the intervention was the placement of a wander guard bracelet (device worn by residents which automatically locks any facility exterior doors and sounds an alarm when approached by residents) on the resident's ankle. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview Mental Status (BIMS). Continued review revealed the resident required supervision for bed mobility, transfers, and toilet use with 1 person assist, and required limited assist for bathing with 1 person assist. Review of a facility investigation dated 2/26/18 revealed, on 2/25/18 at approximately 9:00 PM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 10:15 PM, Resident #1 was returned to the facility by the alleged perpetrator, smelled of alcohol, and was unable to stand and exit the alleged perpetrator's vehicle. Further review revealed Licensed Practical Nurse (LPN) #2 and Certified Nurse Assistant (CNA) #4 assisted Resident #1 out of the vehicle, transferred her into a wheelchair, and took her to her room. Continued review revealed Resident #1 reported the alleged perpetrator took her out of the facility, got her drunk, and sexually assaulted her. LPN #2 notified the Nurse Practitioner (NP) and an order was obtained to send the resident to the hospital for evaluation and treatment. Medical record review of an acute care hospital nurse's triage note dated 2/25/18 at 11:14 PM, revealed .presenting complaint .EMS (emergency medical services) states called to (facility) for altered mental status .staff told EMS that another resident took pt's (patient's) wondering (wander) bracelet off of her and took her somewhere .pt. returned to facility intoxicated .asked what he had done to her .resident replied 'I (sexually assaulted)' .KPD (Knoxville Police Department) present at this time . Continued review of a hospital physician's note dated 2/26/18 at 5:01 AM revealed .patient is in nursing home due to prior TBI [MEDICAL CONDITIONS]([MEDICAL CONDITION]). She was taken out of the NH (nursing home) by another resident's family. She returned intoxicated and stated she had been sexually assaulted . Medical record review of a nurse's note dated 2/25/18 at 11:46 PM (documented after the resident was sent to the hospital) revealed .Resident observed with slurred speech, unable walk or stand without assist, C/O (complains of) lower ABD (Abdominal) pain. Call to NP .sent to ER (emergency room ) for evaluation . Medical record review of a hospital laboratory test result dated 2/26/18 revealed the resident's blood alcohol level was 0.19% (twice the legal limit). Medical record review of a psychiatric services progress note dated 2/26/18 and signed by Advanced Practice Nurse (APN) #2 revealed .History of Present illness: long term resident seen today for follow up at the request of staff. Last night, patient (Resident #1) was drinking with another resident and her male friend in facility. This patient (Resident #1) and the male friend cut off her wander guard, and exited facility and continued drinking. Patient has reported while she was out of the facility she was raped by male she was with .Staff report today, patient has been tearful and keeps to herself. She reports being 'sore' .recommend addition of [MEDICATION NAME] (antianxiety medication) 0.5 mg (milligrams) BID (twice daily) PRN (as needed) X (times) 7 days . Medical record review of a skin assessment dated [DATE] revealed .Site Lt (left) elbow, Description Bruise; Site Between Legs Description Red Bruises; Site Top of Lt hand Description Bruise; Site Rt (right) forearm Description Bruise . Observation and interview with Resident #1 on 5/1/18 at 2:30 PM, in her room, revealed .I knew him from that room over there where we go smoke .he was drinking and he was talking to me and we was going to get beer .don't like to talk about it (incident) . the psychiatrist is supposed to help me (coping with emotions from the assault) .I hope he (perpetrator) was put in jail .we went out the side door on the long hall (Northeast side of the building) .he forced himself on me . Observation on 5/1/18 revealed the facility had 4 entrance/exit doors with keypads that required a code to open or enter/exit: 1 main entrance doorway; 1 ambulance entrance/exit visible from nurse station #1; and 2 entrance/exit doors on the Northeast side of the building, which lead to the parking lot, with one of those doors visible from nurse station #2 and the other door not visible from any nurses station. Interview with the Maintenance Director on 5/2/18 at 4:15 PM, in his office, revealed .(Resident #1) wore a wander guard bracelet and on the day of the incident family members, friends, and all staff had the code to the doors .the same code was used on all of the doors .would change the door code monthly . Interview with the Social Services Director on 5/2/18 at 6:30 PM, in the conference room, revealed Resident #1 .is alert and oriented and can answer questions but her decision making and memory is not good .can try and educate her but she won't remember .met with her daily for 5 days (2/26/18 - 3/1/18) .still visit her weekly .the psychologist continues to visit her . Interview with Certified Nurse Assistant (CNA) #4 on 5/2/18 at 6:55 PM, in the conference room, revealed .it was after dinner .was making (resident) rounds .noticed (Resident #1) in (another resident's) room talking to the resident and her boyfriend .she does not normally go into the room .I went into the room and when I entered they all snickered .I went and told (LPN # 2) I thought something was going on and she told me to tell them both to leave the room .was always suspicious of him .he would say off the wall things .we looked everywhere .I got in my car and drove up and down (street) because I knew what his van looked like .just after I returned to the facility (LPN #2) asked me to come help her because (Resident #1) could not get out of the van .around 10:15 PM .Seemed like she (resident) was intoxicated or on something .she said 'He got me (expletive) up' .he (alleged perpetrator) was making excuses .her wander guard was found in the trash .was cut off . Interview with the Nurse Practitioner (NP) #1 on 5/3/18 at 10:45 AM, in the conference room, revealed .She (Resident #1) changes her story but consistently says he raped her .I think he brought in alcohol and enticed her .she is classic [MEDICAL CONDITION] .history of substance abuse .does not have the ability to make good decisions . Interview with LPN #3 on 5/3/18 at 11:00 AM, in the conference room, confirmed completion of a skin assessment on 2/26/18, which revealed Resident #1 had bruises to bilateral elbows, left wrist, right forearm, redness to both knees, and redness and bruising between her thighs. Continued interview revealed .she had knots on her head .she told me he pulled her hair . Interview with the Clinical Psychologist on 5/3/18 at 11:30 AM, in the activity room, revealed .the ability to make good decisions is not there .she (Resident #1) still having flashbacks .still has anger about the situation .has had an increase in the number of outbursts . Telephone interview with the Violent Crimes Investigator on 5/7/18 at 9:00 AM, revealed .The case is still open .will take another 2-3 months to get the results of the DNA (deoxyribonucleic acid) testing . Interview with Resident #1 on 5/7/18 at 9:40 AM, in her room, revealed .He (alleged perpetrator) cut it (wander guard) off in that room over (another resident's room) there and threw it in the garbage can . Interview with the Administrator on 5/7/18 at 11:00 AM, in his office, revealed .No one saw them leave .we had a camera malfunction .we think they went out the side door .they wouldn't have been seen going out that door .He had been given the door code. At that point in time visitors had the door code . Telephone interview with Resident #1's Physician (Medical Director) on 5/7/18 at 11:45 AM, revealed .She clearly has a cognitive impairment .needs supervision .this has been a learning experience .hard to imagine this would happen . Telephone interview with LPN #2 on 5/7/18 at 5:00 PM revealed .I was passing medications when (CNA #) came up and said he thought something was going on in the room (another resident's room). I told him (Resident #1) needed to go back to her room and he (alleged perpetrator) needed to leave .saw her come out and go down hallway toward her room .she looked mad .did not see him leave .thought I would talk with her in a few minutes .my main concern was to get her out of that room .did you ever see someone and just think I don't like them .nothing could put your finger on .maybe just how he looked .nothing he had done .the night before he gave (Resident #1) a soda and I told him he could not give residents food or drinks because they may have diet restrictions .at that time the (door) code was the current month and year. It was changed monthly; everybody just knew it . Continued interview revealed LPN #2 was not aware anyone had been drinking alcohol in the resident's room and LPN #2 did not go check on Resident #1. Interview with CNA #8 on 5/8/18 at 8:15 AM, on the 200 hallway, revealed since the incident .no one comes in and out the side doors unless a staff member lets someone in the handicapped accessible door .that is monitored by a camera at nurse station 1 .employees have to enter and exit through the front doors also .in-serviced to report any suspicious persons or activity to nurse or supervisor . Interview with LPN #4 on 5/8/18 at 8:45 AM, at nurse station #1, confirmed staff education since the event on 2/25/18 included to immediately investigate any concern of suspicious activity, and also to report the suspicious activity to the supervisor immediately. Interview with the Speech Language Pathologist on 5/8/18 at 9:00 AM, in the conference room, confirmed Resident #1 completed the Saint Louis University Mental Status Examination, not dated, with a score of 6 (indictor of dementia) on a scale to 30. Further interview revealed the resident completed the Montreal Cognitive Assessment on 2/27/18 with a score of 17 on a scale to 30 (score equal to or greater than 26 indicates normal cognition). Continued interview revealed .she (Resident #1) has deficits with higher level thinking skills .that has been consistent since she has been here .she says she wants to go home, leave, go to a motel .she does not comprehend that she would need money .feel like she is still at risk for elopement .she has mentioned to me in therapy that she still wants alcohol and drugs . The facility's corrective action plan included the following: On 2/25/18 the facility did the following: The facility checked the placement and functionality of wander guard bracelets (a device worn by residents that will automatically lock any facility exterior doors and sound an alarm when approached by residents) of all residents identified as being at risk for elopement. On 2/26/17 the facility did the following: A. The Nursing Home Administrator, Director of Nursing Services, Director of Social Services, Director of Activities, Director of Nutrition, Business Office Manager, Maintenance Director, Director of Rehabilitation, Medical Director, Minimum Data Set Coordinator, Director of Admissions, and Licensed Practical Nurse (LPN) #3 conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. B. The Maintenance Director changed the codes to all the exterior entrance/exit doors. C. Conducted in-services with staff on abuse, reporting any unusual appearing activity and systemic changes that were implemented to enhance resident/staff safety. Staff was required to complete a post test. Systemic changes and in-services included: 1. A book placed at the entrance of the facility for visitors/vendors to sign-in and sign-out, all visitors/vendors are to sign when they arrive and when they exit the facility. 2. The door code is not to be given to any resident, visitor, or vendor under any circumstances; staff are to direct the visitor/vendor to the front door and the receptionist will assist the visitor/vendor. If a receptionist is not at the door the staff member will enter the code and let the visitor out the front door. The front door will be the only entrance and exit for the facility. All other exits will be used for emergencies only. If the code is given to any resident, visitor, or vendor disciplinary action will be taken. 3. If staff witness any activity in the facility that they feel is different or odd they report it to their supervisor immediately. The supervisor is responsible to investigate immediately and notify the Executive Director (ED) and/or Director of Nursing Services (DNS). D. Audited to ensure all residents at risk for elopement were assessed accurately. E. Head to toe skin assessment completed for all non-interviewable residents. F. Safe surveys (interviews with residents to determine their safety) were completed with all alert and oriented residents. G. Posted a photo at both nurses station of the alleged perpetrator. H. Notification was given to the alleged perpetrator's girlfriend (also a resident) that he was not allowed to visit. I. Family notification by mail of a change in the process for entrance/exit to the facility was completed for 100% of the families. J. The DNS or designee initiated a daily walk through on both shifts, on all hallways, and interviews with staff to ensure no unusual behaviors, reported allegations of abuse, or any unauthorized entry/exit of the doors on the Northeast side of the facility had occurred. This process is ongoing. K. The Administrator began an audit of all allegations of abuse or reportable incidents and this process is ongoing. L. The facility implemented an elopement drill twice monthly for 2 months, and then monthly, ongoing. On 2/27/18 the facility did the following: A. Conducted an ad hoc Quality Assurance meeting to ensure all interventions of the immediate action plan were implemented. B. Continued staff in-services and post tests for 100% completion of all staff. The surveyor verified the facility's corrective action plan as follows: A. Review of the Quality Assurance Meeting, Attendance, and Agenda sheets confirmed the facility conducted ad hoc Quality Assurance meetings on 2/26/18, 2/27/18, and began review monthly on 3/21/18 to ensure sustainability of the plan of correction. B. Comparison of the room roster dated 2/26/18 with the completed safe survey individual questionnaires and completed skin assessments revealed all residents were assessed for abuse between 2/26/18 - 2/27/18 with 100% completion on 2/27/18. The facility completed weekly safe survey individual questionnaires through 3/22/18 and weekly skin assessments are ongoing. C. Medical record review revealed the 4 residents at risk for elopement on 2/25/18 were re-evaluated using the Unsafe Wandering Risk Evaluation with 100% completion on 2/27/18. D. Nursing Home Administrator on 5/2/18 at 2:45 PM, in the conference room, confirmed letters were mailed to all responsible parties on 2/26/17 to inform of the new process of entering and exiting the facility. Continued interview revealed the Administrator began auditing all allegations of abuse or any reportable incident for timely reporting to the state agency and is ongoing. E. Observation of the wander guard tracking log, door alarms, and interview with the Maintenance Director on 5/2/18 at 4:10 PM, in the maintenance room, confirmed the wander guards are checked weekly for expiration date, function, and door alarm. Continued interview confirmed the keypad code for all entrance/exit doors was changed on 2/26/18 and the implementation of the use of 1 door for entry/exit of the facility. The facility staff must enter the door code to allow visitors/vendors exit from the facility. F. Medical record review of a progress note dated 2/26/18 and interview with the Social Service Director on 5/2/18 at 6:30 PM, in the conference room, confirmed the perpetrator's girlfriend was notified he was no longer allowed to visit. G. Review of a facility document Room Roster (list of wandering residents) initiated 2/25/18, revealed the roster was used to document verification all residents identified as at risk for elopement were accounted for and to document verification of placement and function of the wander guards. Interview with LPN #2 on 5/2/18 at 7:00 PM, in the conference room, and review of the documentation, confirmed residents identified for risk of elopement had a functioning wander guard in place. H. Comparison of facility in-service records, sign in/out sheets, employee roster, and post tests for systemic changes and abuse dated 2/26/18 -2/27/18, and interview with the Director of Nursing Services (DNS) on 5/8/18 at 8:00 AM, in the conference room, confirmed staff education was 100% complete on 2/27/18. Continued review of the facility visitor sign in/out log and interview confirmed the facility initiated the process on 2/26/18 and is ongoing. Further interview with the DNS confirmed the process is monitored daily by DNS or designee which included: a walk through on all hallways, interviews with staff for any unusual behaviors, any allegation of abuse, and monitoring of visitor entrance and exit through the designated entrance door. Continued interview revealed the facility had conducted drills with facility staff for elopement on 2/26/18, 2/28/18, 3/6/18, 3/19/18, 4/4/18, and 5/3/18, and continues monthly. I. On 5/8/18 at 8:40 AM the surveyor attempted to exit through the doorway located on the Northeast side of the building setting off the alarm. The facility staff responded immediately and implemented the elopement protocol. J. Multiple observations and interviews were conducted by the surveyor with residents, visitors, and employees on both shifts throughout the complaint survey conducted from 5/1/18 through 5/8/18, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting of any unusual appearing activity.

Based on facility policy review, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse to the State Survey Agency timely for 1 resident (#1) of 5 residents reviewed for abuse. Resident #1 was sexually assaulted and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator was informed of the Immediate Jeopardy (IJ) on 5/7/18 at 11:00 AM, in his office. The IJ was effective from 2/25/18 through 2/27/18. The IJ was removed on 2/28/18. The facility's corrective action plan which removed the immediacy of the jeopardy was received and corrective actions were validated onsite by the surveyor on 5/7/18 and 5/8/18. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings included: Review of the facility policy, Abuse, dated 11/28/17 revealed .2. The center staff reports any alleged violations involving verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source and misappropriation immediately to a Senior Clinician, or Operational Leader at the facility, or District, or National Level and to other officials in accordance with State regulations through established procedures (including to State survey and certification agency) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Further review revealed the resident required supervision for bed mobility, transfers, and toilet use with 1 person assist, and required limited assist for bathing with 1 person assist. Medical record review of an acute care hospital nurse's triage note dated 2/25/18 at 11:14 PM, revealed .presenting complaint .staff told EMS (Emergency Medical Services) that another resident took pt's (patient's) wondering (wander) bracelet off of her and took her somewhere .pt returned to facility intoxicated . Continued review of a hospital physician's note dated 2/26/18 at 5:01 AM revealed .She was taken out of the NH (nursing home) by another resident's family. She returned intoxicated and stated she had been sexually assaulted . Review of a facility investigation dated 2/26/18 revealed on the evening of 2/25/18, Resident #1 left the facility with the boyfriend of another resident, returned to the facility intoxicated, and alleged she had been sexually assaulted. Interview with the Administrator on 5/3/18 at 11:15 AM, in his office, revealed .I either faxed or called the State Agency that evening (2/25/18) .don't remember . Continued interview revealed the Administrator did not have documentation to support notification of the incident to the State Agency within 2 hours. Review of the facility self-report, and interview with the Director of Nursing on 5/3/18 at 11:15 AM, in the Administrator's office, confirmed the facility reported the incident to the state survey agency on the morning of 2/26/18 (at 8:43 AM, approximately 10 ½ hours after the incident). The facility's corrective action plan included the following: On 2/26/17 the facility did the following: A. The Nursing Home Administrator, Director of Nursing Services, Director of Social Services, Director of Activities, Director of Nutrition, Business Office Manager, Maintenance Director, Director of Rehabilitation, Medical Director, Minimum Data Set Coordinator, Director of Admissions, and Licensed Practical Nurse (LPN) #3 conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. B. Conducted in-services with staff on abuse, reporting any unusual appearing activity and systemic changes that were implemented to enhance resident/staff safety. Staff was required to complete a post test. Systemic changes and in-services included if staff witness any activity in the facility that they feel is different or odd, they report it to their supervisor immediately. The supervisor is responsible to investigate immediately and notify the Executive Director (ED) and/or Director of Nursing Services (DNS). C. Head to toe skin assessment completed for all non-interviewable residents. D. Safe surveys (interviews with residents to determine their safety) were completed with all alert and oriented residents. E. The DNS or designee initiated a daily walk through on both shifts, on all hallways, and interviews with staff to ensure no unusual behaviors, reported allegations of abuse, or any unauthorized entry/exit of the doors on the Northeast side of the facility had occurred. This process is ongoing. F. The Administrator began an audit of all allegations of abuse or reportable incidents and this process is ongoing. On 2/27/18 the facility did the following: A. Conducted an ad hoc Quality Assurance meeting to ensure all interventions of the immediate action plan were implemented. B. Continued staff in-services and post tests for 100% completion of all staff. The surveyor verified the facility's corrective action plan as follows: A. Review of the Quality Assurance Meeting, Attendance, and Agenda sheets confirmed the facility conducted ad hoc Quality Assurance meetings on 2/26/18, 2/27/18, and began review monthly on 3/21/18 to ensure sustainability of the plan of correction. B. Comparison of the room roster dated 2/26/18 with the completed safe survey individual questionnaires and completed skin assessments revealed all residents were assessed for abuse between 2/26/18 - 2/27/18 with 100% completion on 2/27/18. The facility completed weekly safe survey individual questionnaires through 3/22/18 and weekly skin assessments are ongoing. C. Nursing Home Administrator on 5/2/18 at 2:45 PM, in the conference room, revealed the Administrator began auditing all allegations of abuse or any reportable incident for timely reporting to the state agency and is ongoing. D. Comparison of facility in-service records, employee roster, and post tests for systemic changes and abuse dated 2/26/18 -2/27/18. Interview with the Director of Nursing Services (DNS) on 5/8/18 at 8:00 AM, in the conference room, confirmed staff education was 100% complete on 2/27/18. Further interview with the DNS confirmed the process is monitored daily by DNS or designee which included: a walk through on all hallways, interviews with staff for any unusual behaviors, any allegation of abuse, and monitoring of visitor entrance and exit through the designated entrance door. E. Multiple observations and interviews were conducted by the surveyor with residents, visitors, and employees on both shifts throughout the complaint survey conducted from 5/1/18 through 5/8/18, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting of any unusual appearing activity. F. Review of all of the facility's self-reported incidents to the State Survey Agency and allegations of abuse revealed the facility had no other regulatory deficiencies since implementation of the Plan of Correction.

Based on review of facility policy, medical record review, review of a Resident Review Report Worksheet (facility investigation), interview, observation, review of Preventative Maintenance Task Sheet, review of in-service sign-in sheets and roster, review of activity calendars, and Performance Improvement form, the facility failed to supervise, provide a safe environment, and follow the facility's elopement policy, for one resident (#7) assessed at a high risk for elopement of six residents identified for elopement risk. The facility's failure placed Resident #7 in Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death). The Nursing Home Administrator, Director of Nursing (DON), and District Director of Clinical Services, were notified of the Immediate Jeopardy on December 2, 2014, at 2:00 p.m., in the Activity Room. F 323 resulted in Substandard Quality of Care. The findings included: Review of facility policy, Patient Elopement, dated November 11, 2013, revealed "Elopement is when a patient leaves the premises or a safe area without authorization...initiate as soon as the patient is noticed missing the Missing Patient Search Checklist...Conduct searches in an expedient, efficient, calm, and thorough manner...Search areas may include, but are not limited to: Inside Center...Center Grounds..." Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed Resident #7 was discharged on [DATE] with son to a facility with a locked secure unit. Medical record review of a Wander/Elopement Risk Evaluation dated August 30, 2014, revealed "...wanders the facility...unable to stay seated or lying down for more than 10 minutes..." Further review revealed interventions for safety included "...personal alarms on bed and wheelchair..." Medical record review of the initial Minimum Data Set (MDS) dated [DATE], revealed the resident was coded 6 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of one for transfer, dressing, and hygiene/bathing. Continued review of the MDS revealed Resident #7 required limited assist of one for ambulation. Medical record review of the Care Plan initiated on September 5, 2014, revealed the resident "...at risk for elopement/wandering as evidenced by decreased safety awareness, impaired communication problems..." Further review of the care plan revealed interventions for elopement risk included "...address wandering behavior by walking with or attempt to redirect from in appropriate area; engage in diversional activity...elopement risk assessment upon admission, quarterly and with significant change in status...photograph of (resident) in wander notebook..." Review of facility, Resident Event Report Worksheet (facility investigation), dated September 5, 2014, at 6:19 p.m., revealed Resident #7 was found out of the building, off premises, and returned to the facility. Medical record review of a Progress Note dated September 5, 2014, at 6:19 p.m., revealed "Resident was observed on the sidewalk in front of the building walking north. CNA (Certified Nursing Assistant) #6 and LPN (Licensed Practical Nurse) #4 brought resident back in without incident. Resident could not tell us (staff) which door (resident) got out of. According to another resident's family member which said heard door alarm on the other end of the building (side 2). Spoke to both nurses and they did not hear the door alarms on. They (nurses) believe it was the door by the time clock." Medical record review of a Progress Note dated September 5, 2014, at 6:25 p.m., revealed the resident was brought back in safely after the incident, placed in a wheelchair with a new order written for a wheelchair seat belt. Continued review revealed the resident was monitored to determine whether the seat belt could be released without assistance. Interview with the Administrator on November 17, 2014, at 3:10 p.m., in the Activity Room revealed Resident #7 had exited out the door on the side of the building next to the time clock and the DON's office. Further interview revealed the door alarm sounded and Registered Nurse (RN) #1 responded by going to the door and looking out the two windows in the door. Continued interview revealed upon not seeing anyone outside through the windows, RN #1 reset the door alarm and walked around the inside of the building. Further interview with the Administrator revealed RN #1 did not go outside, did not initiate a head count, and proceeded to return to regular work duties. Continued interview with the Administrator revealed Resident #7 had walked down seven steps, gone around the side of the building through the parking lot toward the front entrance of the facility. Further interview revealed Resident #7 was first observed out a window, facing the front of the facility, by CNA (#6) who was feeding another resident. Continued interview revealed CNA #6 ran out of the resident's room, yelled for LPN #4 and both staff members ran outside to get to the resident. Further interview revealed at the time the staff arrived to the resident to return inside the facility, Resident #7 was on the sidewalk beside a busy four lane highway. Observation on November 17, 2014, at 3:30 p.m., of the exit door next to the therapy department, revealed two staff members responded by reporting to the site of the door alarm sounding within a 30 second timeframe. Observation outside the facility with the Administrator on November 17, 2014, at 3:45 p.m., revealed Resident #7 had gone out the door in between the DON's office and the Dietary Department entrance, down seven steps, around the corner of the facility in the paved parking lot, to the front of the building where the resident was first seen by a staff member, and then was on the sidewalk (next to a transformer) beside the busy four lane highway when the staff arrived. Observation with the Administrator on November 18, 2014, beginning at 10:55 a.m., of the nine exit door alarms, revealed all door alarms sounded properly with timely staff response. Interview with the DON on November 18, 2014, at 2:00 p.m., in the Activity Room revealed during the facility's investigation it was determined Resident #7 was seen at approximately 6:05 p.m. on September 5, 2014, talking with another resident's family. Further review revealed the door alarm sounded at approximately 6:10 p.m. and the resident was returned at 6:19 p.m. Continued interview revealed the facility's process when a door alarm sounds is "go to the door immediately, look for a resident, go outside if necessary and look...search the premises, and if not found to return inside, report to the nurse, and initiate a head count." Further interview with the DON confirmed RN #1 did not follow the facility's policy and did not go outside to search for the resident but turned the door alarm off after looking out the glass window of the door. Interview with LPN #4 on November 18, 2014, at 3:10 p.m., in the Activity Room, revealed LPN #4 was at the medication cart outside the 100 hall nurses station when CNA #6 yelled a resident was outside the facility. Continued interview with LPN #4 revealed Resident #7 was next to the transformer on the sidewalk next to the four lane highway. Further interview revealed the resident was wearing sweat pants and a tee shirt at the time of the elopement. Continued interview revealed the resident stated "I'm going home." Further interview with LPN #4 revealed the LPN last saw Resident #7 approximately "six minutes" prior to finding the resident outside. Interview with CNA #6 on November 18, 2014, at 3:25 p.m., in the Activity Room revealed on September 5, 2014, CNA #6 was feeding another resident and looked out of the window at which time the CNA saw Resident #7. Continued interview revealed CNA #6 ran to the hallway and yelled at LPN #4 the resident was outside the facility. Further interview revealed when CNA #6 first saw Resident #7, the resident was in the front parking lot in front of the entrance to the facility. Continued interview with CNA #6 revealed CNA #6 and LPN #4 ran outside the facility and when they arrived at Resident #7's side, the resident was on the sidewalk next to the busy four lane highway. Interview with RN #1 on November 19, 2014, at 3:40 p.m., in the Activity Room, revealed RN #1 was on duty September 5, 2014, and did not remember which door Resident #7 had gone out. Continued interview revealed RN #1 did remember signing a Performance Improvement Form related to the elopement incident with Resident #7 but was unsure of the door the resident had gone out. Further interview revealed when the door alarm sounded, RN #1 went to the door next to the time clock, but RN #1 "couldn't tell which alarm was going off." Continued interview revealed RN #1 did not remember resetting the alarm but remembered pushing on the door in the dining room and the door was locked. Further interview revealed RN #1 went around the building on the inside and by the time the RN had gone around the building, someone had seen Resident #7. Continued interview with RN #1 revealed, "Probably should have gone outside." Interview with the Maintenance Director on November 19, 2014, at 5:00 p.m., in the Activity Room revealed on September 5, 2014, Resident #7 had walked approximately 284 feet outside from the exit door, down seven steps, and to the front entrance where CNA #6 first observed the resident. Further interview revealed the resident walked approximately another 100 feet from the time first observed by CNA #6 to the time CNA #6 and LPN #4 got to the resident standing on the sidewalk next to the busy four lane highway. Review of facility, Resident Event Report Worksheet, dated September 5, 2014, at 6:19 p.m., revealed new interventions for Resident #7 included self-release seat belt and wanderguard. The Immediate Jeopardy was effective from September 5, 2014, through September 9, 2014. The immediacy of the jeopardy was removed on September 10, 2014, and corrective actions were validated onsite by the surveyor through review of documents, staff interviews, and observations on December 3, 2014. The surveyor verified compliance by: 1. Corrective actions validated for Resident #7 included: a. Review of the facility's documentation of every 15 minute checks for Resident #7, revealed every 15 minute checks were initiated September 5, 2014, at 6:20 p.m., and continued until discharge on [DATE] at 4:00 p.m. b. Review of Resident #7's activity calendar from September 5, 2014, through September 17, 2014, revealed Resident #7 attended at least one group activity daily. c. Medical record review of a Progress Note for Resident #7 dated September 11, 2014, revealed "...one on one has stopped at this time, every 15 minute checks continue..." d. Interview with the Activity Director on December 2, 2014, at 8:40 a.m., in the Activity Room, revealed Resident #7 attended group activities daily. Further interview revealed the resident was also kept in small group or 1 on 1 activities such as walking with the Activity Director or Assistant Activity Director. Continued interview revealed the Activity Assistant also works weekends and would walk with the resident on weekends. Further interview with the Activity Director revealed volunteers were also utilized to do one on one with Resident #7. e. Interview with the Administrative Assistant on December 2, 2014, at 9:20 a.m., in the Activity Room revealed extra staff had been scheduled to stay with Resident #7 one on one. Further interview revealed "Someone knew where (resident) was at all times...we stuck to (resident) like glue..." f. Review of a Performance Improvement Form, dated September 8, 2014, revealed RN #1 received a written warning related to "Employee did not follow procedure related to patient elopement. Door alarm was sounding and employee went to the door, closed the door and alarm was reset. Employee did not check the parking lot and surrounding area for a patient and employee did not immediately put the patient head count into effect to ensure all patients were accounted for." Further review revealed RN #1 signed the form on September 8, 2014. 2. Corrective actions validated for residents at risk for elopement included: a. Review of the Preventative Maintenance Task Sheet revealed on September 5, 2014, the wandering resident bracelet testing was performed on the wanderguards of five current residents including a spare bracelet. b. Observation of the signs on each exit door on December 2, 2014, at 11:20 a.m., revealed each door had at least three signs stating "Please: Speak with our staff members before letting anyone out of this door. This will ensure our residents remain safe...Emergency Exit Alarm will Sound. Please use front door...Push Until Alarm Sounds - Door can be opened in 15 seconds..." c. Interview with the Admissions Coordinator on December 2, 2014, at 11:00 a.m., in the Activity Room revealed on admission the family or the responsible party are in-serviced on the door alarms, the entrance and exit door, and to observe for any resident following the family to a door. 3. Review of the facility's in-service records related to the door alarms, random elopement drills, and interviews with employees, family members, and a volunteer revealed: a. Review of the facility's in-service sign in sheets related to the door alarms, revealed in-service regarding when a door alarm sounds, go to the alarm, look at the surroundings, look outside, walk around the building, and if a resident is not found return to the inside of the building to initiate a head count. Continued review of the facility in-service sign-in sheets revealed drills were initiated during the 3-11 p.m. shift on September 5, 2014, and continued for all shifts on September 6, 8, 9, 10, 2014, with 100% of employees in-serviced including contract housekeeping staff. Further review of the in-service records revealed the wanderguard system was also discussed during the in-services. b. Review of the facility's in-service attendance roster related to random elopement drills, revealed the drills were conducted on September 9, 11, 19, 23, 29, 2014, and October 4, 16, 22, 28, 2014. c. Interviews were conducted on December 2-3, 2014, with five family members and one volunteer related to the door alarms, exit doors, and wanderers. Each family member was aware of the door alarms, exit doors, and aware to watch for residents upon exit. Further interview with the volunteer revealed the Activity Director, who is responsible for the volunteer program, gave the volunteer a copy of the elopement policy and procedure and discussed the policy prior to working with the residents. d. Interviews were conducted on December 2-3, 2014, with ten employees, including housekeeping (contract services), Occupational Therapy Assistant, Activities Assistant, and licensed and non-licensed staff on the 7-3 and 3-11 shifts. The staff members were asked if they attended an in-service on the elopement policy including the door alarms and procedure to follow if a door alarm sounded. Interviews revealed each staff member had attended one or more of the in-services and drills, and could repeat the process to follow once a door alarm sounded or a head count was initiated. 3. Monitoring and Quality Assurance: a. Review of a plan for correction developed during an ad hoc Performance Improvement Meeting dated September 9, 2014, revealed an agenda topic related to Elopement. Continued review revealed the interventions included "...In-services...review of policy and procedures for all staff...audit of resident pictures...Residents who are assessed to be an elopement risk to have BIMS completed within 24 hours of assessment...alert to be placed to state new admit or residents assessed to be a new elopement risk...two photos to be available...elopement policy and procedure to be reviewed in new employee orientation and at least annually...elopement drill...Resident continues on 15 minute checks..." b. Interview with the DON on December 2, 2014, at 12:45 p.m., in the Activity Room, revealed the QA (Quality Assurance) related to elopement continues monthly even if no elopements have occurred. Further interview with the DON revealed elopements are discussed each day during the morning meeting. Review of the facility's Corrective Action Timeline following the elopement on September 5, 2014, revealed systemic changes that will be included "Elopement Policy/Procedure will be discussed at General, Nursing, and CNA monthly meetings...drills will be completed on a monthly basis...elopement has always been discussed in orientation; it will be added to check list for confirmation...weekend activities assistant to take newly admitted Residents who are admitted Friday night and thru the weekend." C/O #

Based on medical record review, review of the facility's post fall evaluations and interview, the facility failed to ensure interventions were put place to reduce the risk of falls and failed to assess whether interventions were in place at the time of falls for one resident (#5) with a history of frequent falls with injuries of five residents reviewed. The facility's failure resulted in harm with repeated injury falls for resident #5. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had intact cognitive skills; required extensive assistance with bed mobility, transfers, ambulation and bathing; was not steady with moving from a seated to a standing position, walking, turning around, moving off and on the toilet and with surface-to-surface transfers; had impairment in range of motion of the upper and lower extremities on one side; and was frequently incontinent of urine and bowel. Medical record review of nurses' notes dated August 2010, revealed the resident had five falls in August 2010: August 4-"Resident stated...wasted...ice on the floor and...was trying to pick it up and slipped and fell ...skin tears..."; August 25-sitting in the wheelchair at the time of the fall-abrasions to lower back; August 26 at 11:45 a.m.-unassisted ambulation from wheelchair-no documented injury but confused; August 26 at 12:00 noon-unassisted ambulation from wheelchair-no documented injury. A pressure sensitive alarm was placed in the wheelchair and the bed on August 27, 2010; and August 28-in the wheelchair at the time of the fall and "fell to floor...hit head on floor et (and) received 4 sm (small) lacerations a sm skin tear on (L) hand...transfer to (hospital)." The resident was readmitted to the facility on [DATE]. Medical record review revealed the pressure sensitive alarm was removed from the bed and wheelchair on September 2, 2010, because the resident was non-compliant with the use of the devices and would remove the alarms. Medical record review of nurses' notes revealed no additional interventions were put in place to reduce the risk of the resident standing from the wheelchair and falling. Medical record review of fall risk assessments dated September 1 and November 5, 2010, revealed the resident was at high risk for falls. Medical record review of the care plans dated July 18, 2010, and November 28, 2010, revealed the resident was at risk for falls. Medical record review of a nurse's note dated September 29, 2010, at 6:00 a.m., revealed, "...sitting in floor...states, 'I just slipped. I was getting ice...' X-ray of (R) hip is ordered..." The fall occurred while the resident was ambulating unassisted and was "unwitnessed." Review of a nurse's note dated September 29, 2010, at 2:00 p.m., revealed the x-ray was negative for fracture. Medical record review of a nurse's note dated October 4, 2010, at 9:00 p.m., revealed, "...repositioning in WC (wheelchair) at 6pm et (and) graham crackers in floor, foot slipped et resident slip into the floor...small abrasion on (R) upper shoulders, small bruise on (L) upper shoulder, resident voiced hit W/C...voiced did not hit head..." Review of the care plan revealed Dycem (non slip surface) was placed in the wheelchair on October 4, 2010, and was discontinued on October 5, 2010. Medical record review of a nurse's note dated October 17, 2010, at 2:30 p.m., revealed, "...lying in floor on Lt (left) side-rocker stool turned over beside resident...ST (skin tear) to Lt lower leg C-shaped approx. (approximately) 4 cm (centimeters)...Bruise noted to Lt hip...began to c/o (complain of) pain...x-ray Lt hip..." Review of the post fall evaluation dated October 17, 2010, revealed the resident was in the wheelchair prior to the fall. Medical record review of the x-ray results revealed no fracture. Medical record review of a nurse's note dated October 22, 2010, revealed, "...found in floor in front of closet...head against the wall...skin tear to (R) elbow & (and) left leg behind knee...abrasion to the back of head...small amount of bleeding...can not recall how...got in floor...send out to (hospital) for further evaluation...to ER (emergency room )." Review of the post fall evaluation dated October 22, 2010, revealed the resident was in the wheelchair prior to the fall. Medical record review of a nurse's note dated October 22, 2010, at 9:35 p.m., revealed a CT scan and x-ray of the right elbow and right knee were negative. The resident returned to the facility on [DATE], at 10:15 p.m. Review of the care plan revealed a pressure alarm was applied to the bed and wheelchair. Medical record review of a nurse's note dated October 25, 2010, revealed, "Resident @ (at) nurses station, started standing (up). CNA (Certified Nursing Assistant) went to sit resident back (down). Geri chair rolled...Resident went...to floor hitting head on wall @ approx 1010...Lt pupil unresponsive. Resident lethargic...to (hospital) ER for eval. (evaluation)..." Medical record review of a nurse's note dated October 25, 2010, at 5:00 p.m., revealed the resident returned to the facility with, "...1.1 (one-on-one) staff (with) resident to cont (continue) thru-out shift. Lt eye cont to be non-reactive @ this time. Dx (diagnosis) from hosp (hospital)...Closed Head Injury..." Medical record review of a nurse's note dated November 3, 2010, at 5:30 p.m., revealed, "...sitting in front of nurses station in W/C...stood up & fell before nurse and CNA could reach...hit...left ear and has laceration on it...sent to ER for further eval..." Review of a post fall evaluation dated November 3, 2010, revealed, "...left ear requiring stitches..." Medical record review of a nurse's note dated November 5, 2010, revealed the resident returned to the facility two days after the fall. Review of a post fall evaluation dated December 10, 2010, at 5:30 p.m., revealed the resident had an un-witnessed fall from the wheelchair with no apparent injury. Review of a nurse's note dated December 10, 2010, revealed a soft belt restraint was applied to the resident. Review of documentation provided by the facility dated December 28, 2010, revealed the resident fell from the wheelchair on December 28, 2010, and received a skin tear to the right elbow. Review of the documentation revealed no documentation the soft belt was in place at the time of the fall. Medical record review, review of post fall evaluations and the care plan and interview on April 4, 2011, from 3:00 p.m., to 4:30 p.m., in the conference room, with the Administrator and the Director of Nursing (DON), confirmed the resident had frequent falls after standing from the wheelchair and had an abrasion to the right shoulder and a bruise to the left shoulder after the fall on October 4, 2010; had pain in the left hip and a skin tear to the left leg after the fall on October 17, 2010; had an abrasion and a hematoma to the head and a skin tear to the left leg and right elbow after the fall on October 22, 2010; had a Closed Head Injury after the fall on October 25, 2010; had a laceration requiring stitches to the left ear after the fall on November 3, 2010; and had a skin tear to the right elbow after the fall on December 28, 2010. Continued medical record review, review of post fall evaluations and the care plan and interview on April 4, 2011, from 3:00 p.m., to 4:30 p.m., in the conference room, with the Administrator and the Director of Nursing (DON), confirmed a pressure alarm was placed in the wheelchair August 27, 2010, and removed September 2, 2010, because the resident "refused" the alarm. Interview confirmed no additional interventions were attempted after the pressure alarm was removed on September 2, 2010, and prior to the fall on September 28, 2010. Continued interview confirmed the majority of falls occurred after the resident exited the wheelchair, and at the time of the falls on October 17 and 22, 2010, no interventions were in place to reduce the risk of the resident standing from the wheelchair. Continued medical record review, review of post fall evaluations and the care plan and interview on April 4, 2011, from 3:00 p.m., to 4:30 p.m., in the conference room, with the Administrator and the Director of Nursing (DON), confirmed the fall on October 25, 2010, occurred because the geri-chair was not locked and rolled away from the resident when the CNA attempted to sit the resident in the geri-chair. Continued interview confirmed no new interventions were put in place after the resident returned to the facility from the hospital on November 5, 2010, following a fall on November 3, 2010, which required stitches to the left ear. Continued review and interview confirmed the facility had no knowledge if the alarm was in place at the time of the fall on December 10, 2010, and if the Velcro seat belt was in place at the time of the fall on December 28, 2010. C/O #