Every finding on record at Crisp Regional NSG & Rehab CTR

Based on staff interviews, record reviews, and review of the facility's policy titled, Advance Directives, the facility failed to ensure residents/representatives/guardians were informed of and provided written notice of the right to accept or decline medical and surgical treatments and their right to formulate an advance directive for two of two residents (R) (R18 and R79) reviewed.Findings include:Review of R18's electronic medical record (EMR) revealed no documented evidence or signed statement of acknowledgment that the resident and his/her representative were informed or received written information advising of their right to accept or decline medical and surgical treatments and to formulate an Advance Directive.Review of the EMR revealed R18 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R18's Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment.Review R79's EMR revealed no documented evidence or signed statement of acknowledgment, the resident and his/her representative were informed or received written information advising of their right to accept or decline medical and surgical treatments and to formulate an Advance Directive.Review of the EMR revealed resident R79 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R79's BIMS score of 12, indicating moderate cognitive impairment.Interview on 03/25/2026 at 12:25 PM with the Administrator confirmed no evidence was found to support that R18 and R79 and or their representatives had been provided with written information related to their right to accept or refuse medical or surgical treatment and the right to formulate an advance directive, on or after admission to the facility.

Based on observations, staff interviews, record review, and review of the facility's policy titled, LTC (long term care) Care Plan, the facility failed to develop a comprehensive care plan for four of 45 sampled residents (R) (R1, R79, R3, and R62). The facility failed to develop the comprehensive care plan for foley catheter for R1 and R62, dialysis care plan for R3, and activities of daily living (ADLs) care plan for R79. This deficient practice had the potential to cause adverse health outcomes, including increased risk of infection related to unmanaged Foley catheter care, complications or missed treatments associated with dialysis needs, decline in functional status due to lack of appropriate ADL support, and overall diminished quality of care and resident well-being due to the absence of individualized, comprehensive care planning.Findings Include: 1. Review of the facility's policy titled LTC Care Plan undated, documented under Policy: . LTC Care Plan Intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team (IDT), and will reflect the resident's initial strengths, limitations, and goals. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on the resident's needs. A resident should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity of resident care. Review of the electronic medical record (EMR) revealed R79 was admitted to the facility on [DATE] with diagnoses that include included but not limited t epilepsy, respiratory failure, unspecified, anxiety disorder, unspecified. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R79's Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section GG (Functional Abilities) showed: Dependent for: Toileting hygiene, Shower/bathe self, Upper body dressing, Lower body dressing and Personal hygiene. Review of care plan revealed no care plan for ADLs. Review of Physician's Orders revealed no order with indication for ADL Care. Interview on 03/25/2026 at 2:45 PM with the MDS Coordinator AA confirmed there was no care plan for ADL care. She stated the MDS department was responsible to update the care plan and it was not updated. She confirmed that if there was no care plan for ADL care plan then R79 may not get the care that she needed. She further stated that the Certified Nursing Assistants (CNA)s would not see it on their kardex to know the care to provide. 2. Review of the EMR revealed R62 was admitted to the facility on [DATE] with no diagnosis for Foley catheter indication. Review of the Quarterly MDS dated [DATE] revealed in Section C: (Cognition) a BIMS score of 3, which indicated R62 had severely impaired cognition, Section H (Bowel and Bladder) revealed R62 had an external catheter. Review of care plan revealed no care plan for a Foley catheter. Review of Physician's Orders revealed no order with indication for a Foley catheter. Interview on 03/25/2026 at 1:15 PM with Unit Manager (UM) DD revealed she confirmed there was no care plan for R62's Foley catheter. She stated it should be care planned. Interview on 03/25/2026 at 1:20 PM with the Director of Nursing (DON) revealed she confirmed there was no care plan for R62's Foley catheter. She stated that the care plan paints a picture of the residents' care and shows what should be done. Interview on 03/25/2026 at 1:45 PM with the MDS Coordinator AA revealed she confirmed there was no care plan for Foley catheter. She stated the MDS were responsible to update the care plan and it was not updated. Interview on 03/25/2026 at 1:47 PM with MDS EE revealed she confirmed there was no care plan for R62's Foley catheter. She stated that a negative outcome for R62 would be that if the nurses went to the care plan and did not see a care plan for Foley catheter they may not know that he had a Foley catheter and R62 may not receive the care he should receive. She further stated that the Certified Nursing Assistants (CNA)s would not see it on their Kardex to know the care to provide. She stated that the nurse would not know what to do if they did not see it in the care plan and R62 would not get the care that he should receive. 3. Review of the EMR revealed R1 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included end stage renal disease and kidney transplant status. Review of the most recent Quarterly MDS dated [DATE] documented R1's BIM status was not conducted due to R1 being rarely or never understood. Review under section H, Bladder and Bowel, revealed that R1 has an indwelling catheter. Review of R1's care plan revealed no documentation of catheter care. Review of R1's physician orders revealed an order dated 11/10/2025 for urinary catheter care as needed, an order dated 11/20/2025 for urinary catheter care every Tuesday, an order dated 11/20/2025 for urinary catheter 16F (French) 10 mL (milliliter) bulb, an order dated 11/10/2025 for changing the indwelling Foley catheter as needed for occlusion or leakage, an order dated 11/10/2025 for checking the placement of the catheter anchor every shift, an order dated 11/10/2025 to change the urinary catheter drainage bag as needed (PRN), and an order dated 11/10/2025 to change the urinary catheter drainage bag every 30 days. Interview with Director of Nursing (DON) on 03/36/2026 at 10:35 AM revealed that the care planning process begins upon a resident's admission. The DON confirmed that catheters and associated care should be included in the care plan. She stated that if a resident was admitted with a catheter, the physician should be contacted and nursing staff were responsible for adding catheter maintenance, such as Foley care, into the care plan. 4. Review of the EMR revealed R3 was admitted to the facility on [DATE] with no diagnosis for dialysis. Review of the Quarterly MDS assessment dated 01/2026 revealed in Section C, Cognition, R3 had a BIMS score of 13, indicating little or no cognitive decline. Section O, special treatments, procedures, or programs revealed R3 receives dialysis care. Review of physician orders regarding R3 indicates dialysis three days a week, Mon, Wed, and Fri at 2:45 PM. Review of a care plan for R3 revealed no care plan for dialysis. An interview on 03/26/2026 at 10:40 AM with the MDS/Care Plan Coordinator confirmed that R3 did not have a care plan for dialysis. Interview on 03/26/2026 at 10:55 AM with the DON reported that a resident on dialysis should be care planned for dialysis at admission. If a resident does not care have a care plan for dialysis it can lead to a delay in care and possible complications and/or worsening of condition. Interview on 03/26/2026 at 1:15 PM with the Administrator confirmed that a resident should be care planned for any area of need for a resident. Cross reference to F690

Based on observations, staff interviews, record review and review of the facility's policy titled, Foley Catheter Care Policy (Long-Term Care), the facility failed to have order with indication for Foley catheter, and failed to have diagnosis for Foley catheter for one of 12 sampled residents (R) R62 with Foley catheters. This deficient practice had the potential to cause complications and improper care management related to Foley catheter.Findings include: Review of the facility's policy titled Foley Catheter Care Policy (Long-Term Care) dated 06/11/2021 documented 1. Purpose: To ensure safe management of indwelling urinary (Foley) catheters, prevent complications such as Catheter-Associated Urinary Tract Infection, and promote resident comfort and dignity. 2. Policy Statement: Indwelling urinary catheters will be used only when medically necessary, maintained using aseptic technique, and removed as soon as clinically appropriate. All staff will follow evidence-based infection prevention practices.Review of the Electronic Medical Records (EMR) revealed R62 was admitted to the facility on [DATE] with no diagnosis for Foley catheter indication.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C: (Cognition) Brief Interview for Mental Status (BIMS) score of 03, which indicated R62 had severely impaired cognition, Section H (Bowel and Bladder) revealed R62 had external catheter. Review of care plan revealed no care plan for Foley catheter. Review of Physician's Orders revealed no order with indication for Foley catheter.Interview on 03/25/2026 at 01:15 PM with Unit Manager (UM) DD revealed she confirmed there was no diagnosis for the Foley catheter and there was no order with indication for Foley catheter. She stated she did not see a diagnosis in the EMR and after searching R62's files, she stated she did not find any documentation of the indication for R62's Foley catheter. UM DD further stated that R62's orders had no indication for Foley catheter. She stated that when there was no diagnosis for Foley catheter the nurses would not know the reason for the Foley catheter and would not provide the care R62 needed. Interview on 03/25/2026 at 01:20 PM with the Director of Nursing (DON) revealed she confirmed there was no diagnosis for R62's Foley catheter. She further stated the orders had no indication for Foley catheter. The DON stated that when she looked in the EMR and in R62's file there was no indication in the EMR for Foley catheter and if there was no indication for the Foley catheter there may not be adequate treatment and care for the resident's condition. Interview on 03/25/2026 at 01:45 PM with the MDS Coordinator AA revealed she confirmed that there was no diagnosis or indication for R62's Foley catheter. The MDS Coordinator stated she was responsible for placing the diagnosis in the EMR and it was not done. She stated that if the resident did not have a diagnosis for Foley catheter or an indication for Foley catheter the nurses would not know why the resident had a Foley catheter. Interview on 03/25/2026 at 01:47 PM with the MDS EE revealed she stated that there should be a diagnosis in the EMR and there was not. She stated the resident would not be treated properly if there was no diagnosis. MDS EE also confirmed there was no order with an indication for a Foley catheter and without a diagnosis, the nurses would not know why the resident had a Foley catheter and the reason they were treating or caring for the resident. She stated that the nurses would not know what to look for in change in condition and signs and symptoms which would be associated with R62's Foley catheter.

Based on observations, staff interviews and review of the facility's policy titled, LTC- Medication Storage, Medication Administration, Insulin and Insulin Pen Management, Medication Open Date and Eye Drop (Ophthalmic Medication), the facility failed to lock one of four medication carts on the 100 hall and failed to place open dates on two vials of multidose insulin for two residents (R) R66 and R1, two medicated eyedrops for R81 and R63, one insulin pen for R90 and one bottle of blood glucose strips. This deficient practice had the potential to cause unauthorized access to medications and ineffectiveness of medications with no open dates for the residents.Findings include:Review of the facility's policy titled LTC- Medication Storage reviewed December 2025 documented Policy Subject: Medication Storage: 1. Medications must only be accessible to authorized staff, and locked when not under the direct observation of authorized staff, d. The medication cart should always be locked unless in use.Review of the facility's policy titled Medication Administration dated 06/11/2021 documented . 26. The medication cart should always be locked unless in use by the unit nurse.Review of the facility's policy titled Insulin and Insulin Pen Management undated, documented Procedures: 1. Labelling Requirements: All insulin vials and pens must be labelled with Resident name, Date opened; Unlabeled insulin must not be used and must be discarded. 10. Staff responsibility: Licensed nurses and trained medication aides are responsible for: proper labeling and dating.Review of the facility's policy titled Medication Open Date undated, documented Purpose: To ensure all medications are used within safe and effective timeframes after opening, reducing risk of contamination, degradation, or reduced potency. Policy Statement: All medications that are opened, reconstituted, or removed from original manufacturer packaging must be clearly labeled with the date opened and handled according to established beyond-use guidelines. Procedures: 1. Labeling Requirements: 2. All staff must immediately label medications upon opening with: Date opened.Review of the facility's policy titled Eye Drop (Ophthalmic Medication) reviewed December 2025 undated documented Purpose: To ensure all medications are used within safe and effective timeframes after opening, reducing risk of contamination, degradation, or reduced potency. Policy Statement: All medications that are opened, reconstituted, or removed from original manufacturer packaging must be clearly labeled with the date opened and handled according to established beyond-use guidelines. Procedures: 1. Labeling Requirements: All staff must immediately label medications upon opening with: Date opened.Observation on 03/25/2026 at 3:50 PM revealed one medication cart on the 100 hall was observed to be unlocked and unattended. Observation on 03/26/2026 at 9:06 AM during review of nurses' medication cart on the Vent Unit revealed no open dates on one multidose bottle of insulin as part for R66, one multidose vial insulin glargine for R1, one bottle of Olopatadine Hydrochloride ophthalmic solution for R81, one bottle of Olopatadine 0.1% (percent) eye drops for R63, one insulin pen for R90 and one bottle of blood sugar strips.1.Review of the facility's Electronic Medical Records (EMR) revealed R66 was re- admitted to the facility on [DATE] with diagnosis included but not limited to type 2 diabetes mellitus (DM).Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognition) Brief Interview for Mental Status (BIMS) R66 was rarely/never understood, Section N (Medication) on hypoglycemic (including insulin). Review of Physician's Orders dated 3/26/2026 documented included but not limited to HumaLOG Injection Solution 100 UNIT/ML (milliliter) subcutaneously every 6 hours for DM.2. Review of the EMR revealed R1 was re- admitted to the facility on [DATE] with diagnosis included but not limited to type 2 diabetes mellitus.Review of the Quarterly MDS dated [DATE] revealed Section C (Cognition) BIMS score for R1 was rarely/never understood, Section N (Medication) on hypoglycemic (including insulin). Review of Physician's Orders dated 11/07/2025 documented included but not limited to Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously at bedtime for diabetes.3. Review of the facility's EMR revealed R81 was admitted to the facility on [DATE] with diagnosis included but not limited to age-related physical debility.Review of the Quarterly MDS dated [DATE] revealed Section C (Cognition) BIMS score of 15, which indicated R81 had intact cognition. Review of Physician's Orders dated 03/13/2026 documented included but not limited to Olopatadine Ophthalmic Solution 0.2 %, instill 1 drop in both eyes at bedtime for itchy watery eyes.4. Review of the facility's EMR revealed R63 was admitted to the facility on [DATE] with diagnosis included but not limited to allergic rhinitis.Review of the Quarterly MDS dated [DATE] revealed Section C (Cognition) BIMS score of 15, which indicated R63 had intact cognition.Review of Physician's Orders dated 12/18/2024 documented included but not limited to Ophthalmic Solution 0.1 % (Olopatadine HCl) Instill 1 drop in both eyes one time a day for burning eyes 1 drop in each eye daily.5. Review of the EMR revealed R90 was admitted to the facility on [DATE] with diagnosis included but not limited to Type 2 diabetes.Review of Physician's Orders dated 03/12/2026 documented included but not limited to Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale subcutaneously every 6 hours for hyperglycemia.Interview on 03/25/2026 at 3:52 PM with Registered Nurse (RN) CC revealed he confirmed the drawers of the medication cart were unlocked when he opened all the drawers of the medication cart which were unattended in the 100 hallway. RN CC stated the medication cart should be locked. He stated residents could remove medications from the cart and they would overdose on the medications.Interview on 03/25/2026 at 3:53 PM with Unit Manager (UM) DD revealed she confirmed the drawers of the medication cart in the 100 hallway were unlocked. She stated the drawers should be locked. She further stated that the residents could open the drawers of the cart and take the medications.Interview on 03/26 2026 at 9:06 AM with Licensed Practical Nurse (LPN) II revealed she confirmed and validated that there were no open dates on one multidose bottle of insulin aspart for R66, one multidose vial insulin glargine for R1, one bottle of Olopatadine Hydrochloride ophthalmic solution for R81, one bottle of Olopatadine 0.1% eye drops for R63, one insulin pen for R90 and one bottle of blood sugar strips. She stated open dates should be on blood sugar strips, insulin vials and pens, and eye drops. Interview on 03/26 2026 at 9:17 AM with UM JJ revealed she stated that insulin vials and insulin pens were not good after 28 days of being opened. She stated if they were used on the residents, the insulin would not be effective. Interview on 03/26/2026 at 1:30 PM with the Director of Nursing (DON) revealed she stated medication carts should never be unlocked and unattended. The DON stated her expectations were for the nurses to ensure the medication carts were locked when unattended. The DON further stated that all medications should be dated with the date opened and nurses should ensure open dates were placed on medications when first opened.

Based on observations, staff interviews, record review and review of the facility's policies titled, Infection Control Hand Hygiene Trach Care and Foley Catheter Care, the facility failed to ensure adherence to standard infection control practices, including hand hygiene, maintenance of a clean field, proper PPE use during tracheostomy (trach) care for one of 13 sampled residents (R) R41 with tracheostomy, and failed to ensure appropriate catheter care technique, in accordance with accepted standards of practice for one of 12 sampled R (R62) with foley catheter. This deficient practice had the potential to cause infection, medical complications and improper management care.Findings include: Review of the facility's policy titled Infection Control Hand Hygiene dated March 2023 documented Purpose: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting: 1. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, immediately after glove removal. 2. Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Presentation (CDC) recommendations.Review of the facility's policy titled Foley Catheter Care dated 06/11/2021 documented 1. Purpose: To ensure safe management of indwelling urinary (Foley) catheters, prevent complications such as Catheter-Associated Urinary Tract Infection, and promote resident comfort and dignity. 2. Routine Care (Daily & PRN (as needed): Perform perineal care at least daily and after bowel movements, clean catheter from insertion site outward with soap and water.Review of the facility's policy titled Trach Care dated 07/07/2022 documented Trach care is performed every/day and as needed (PRN). Trach cleaning is done to prevent nosocomial, pulmonary, and wound infections.1.Review of the Electronic Medical Records (EMR) revealed R62 was admitted to the facility on [DATE] with no diagnosis for Foley catheter indication.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C: (Cognition) Brief Interview for Mental Status (BIMS) status 03, which indicated R62 had severely impaired cognition, Section H (Bowel and Bladder) R62 had external catheter. Review of care plan revealed no care plan for Foley catheter. Review of Physician's Orders revealed no orders with indication for Foley catheter.Observation on 03/25/2026 at 2:35 PM during R62's Foley catheter care revealed Certified Nursing Assistant CNA GG used one wipe to clean the foley catheter repeatedly at up and down the tubing without folding the wipe. During the observation CNA GG used another wipe to clean around the scrotum and used the same wipe to clean foley catheter tubing.Interview on 03/25/2026 at 3:53 PM with CNA GG revealed she confirmed she wiped the Foley catheter tubing more than once in the same spot up and down the tubing with the same wipe without folding the wipe or disposing of the wipe. 2. Review of the EMR revealed R41 was admitted to the facility on [DATE]. with diagnosis included but not limited to acute and chronic respiratory failure with hypoxia, cardiac arrest, tracheostomy, dependence on respirator [ventilator].Review of the Quarterly MDS dated [DATE] revealed Section C (Cognition) BIMS, R41 was rarely/never understood, Section 0 (Special Treatments, Procedures, and Programs) R41 received Tracheostomy care and was on Invasive Mechanical Ventilator.Review of Physician's Orders dated 08/05/2025 documented included but not limited to Trach Change: Respiratory Therapist to change Trach Tube- once completed add progress note and notate how resident tolerated trach change every day shift every 45 day(s) for To prevent tracheal stenosis and decrease infection. May change as needed (PRN) for dislodgement or malfunction.Observation and interview on 03/25/2026 at 09:11 AM revealed LPN HH was in the 100 hallway and cleaned the blood pressure cuff, removed her gloves, donned a new pair of gloves without sanitizing her hands and cleaned the blood sugar machine. She removed the second pair of gloves, disposed of it in the garbage bin and proceeded to look for medications from the medication cart. LPN HH did not hand sanitize between glove change. Observation on 03/25/2026 at 2:05 PM during R41's trach care revealed Respiratory Therapist (RT) FF removed dressing from the trach site and placed it on the bare bedside table beside the opened sterile trach set, changed gloves and did not hand sanitize, removed inner canular and disposed on bare bedside table. RT FF went in the hallway wearing her gown and gloves on to a cart with wipes which was two rooms down the hallway, returned to the room in the same gown and gloves, and cleaned wiped the bedside table. She then used the same gloves which was used to the clean the trach to press the button on the bed to lower the bed, then pressed the buttons on the ventilator machine to reprogram the machine. Interview on 03/25/2026 at 2:05 PM with RT FF revealed she confirmed she removed the dressing from the trach site and placed it on the bare bedside table beside the opened sterile trach set, changed gloves and did not hand sanitize, removed inner canular and disposed on bare bedside table, went in the hallway wearing her gown and gloves to a cart which was two rooms down the hallway and returned to the room in the same gown and gloves. She confirmed she used the same gloves which were used to clean the trach to press the button on the bed to lower the bed, then pressed the buttons on the ventilator machine to reprogram the machine.Interview on 03/26/2026 at 9:17 AM with Registered Nurse JJ revealed she stated there should be a designated trash bag/bin or area during trach care to dispose of used items. She stated hand hygiene must be completed first before putting on a new pair of gloves hands should be cleaned after removing gloves and before putting on gloves. Interview on 03/26/2026 at 9:29 AM with UM KK revealed she stated her expectations were for hand hygiene to be done before putting on gloves, after removing gloves and between glove change. She stated hands should be sanitized between glove change. UM/RT stated soiled gauze were to be discarded in a garbage can and should not be placed on the bedside table. Interview on 03/26/2026 at 10:04 AM with RN/Infection Preventionist and Educator revealed her expectations were for the staff to practice hand hygiene before entering and after leaving the residents' rooms and between glove change. She stated that once gloves were removed the staff must hand sanitize. Interview on 03/26/2026 at 1:30 PM with the Director of Nursing (DON) revealed she stated hand hygiene must be performed between glove change to prevent infection to the residents. She stated soiled dressings must not be mixed or placed next to sterile dressings or sterile or clean fields as this could lead to cross contamination. The DON stated medication carts should never be unlocked and unattended because the residents may get into the carts.

Based on observations and staff interviews, the facility failed to maintain the garbage storage area in a sanitary manner by ensuring dumpster lids were closed, failed to ensure the surrounding area was free from trash and standing water, failed to ensure one of three dumpsters was in good condition by not leaking. This practice had the potential to attract insects/rodents, and the potential for transmission of disease through the harborage and feeding of pests and carrying microorganisms into the facility. Findings include: Observation on 9/12/2023 at 9:40 a.m., and again that afternoon at 5:00 p.m., revealed two of three dumpsters with large bags of garbage inside with the lid open and trash on the ground. The dumpsters were visible by the survey team from inside the conference room. Observation on 9/13/2023 at 8:13 a.m. revealed two dumpsters containing large bags of garbage inside with the lid open and trash on the ground, visible from inside the conference room. Another observation at 9:12 a.m. of the dumpster area revealed additional bags of trash had been piled on top of the bags from the earlier observation, the dumpster lid was open, free-standing water and trash was on the ground around the dumpsters. Observation and interview on 9/13/2023 at 3:10 p.m. with the Administrator confirmed that the lid was not closed on two of three dumpsters, and there was water and trash on the ground around the dumpsters. The administrator revealed this was unacceptable and she expected the dumpster area to be clean and sanitary. She expected trash to be inside the dumpster, the lid to be closed, expected no drainage around the dumpsters, and revealed it would be corrected immediately. The administrator revealed maintenance was responsible for overseeing the dumpsters, and trash pick-up was once a week unless they called them and requested more often. She revealed there was no policy for dumpster maintenance, and she did not think she had any Inservice records on proper disposal of trash, but there is about to be [sic]. Observation on 9/14/2023 at 8:41 a.m. revealed one of two dumpsters had large bags of trash inside with the lid open, standing water and trash on the ground. Observation on 9/14/2023 at 8:53 a.m. during a tour of the dumpster area with the dietary manager (DM) confirmed that two dumpsters had large bags of trash inside and the lid was open, trash was on the ground, one dumpster had drainage leaking out onto the ground, free-standing water was around the dumpster area, several gloves, and a mask was scattered on the grassy area around the dumpster that was off to the side. The DM stated that the whole facility, not just dietary, put trash in the dumpsters and staff had been instructed on the proper way to discard trash. At that time, she closed all dumpster lids. A short while later the dietary manager informed this surveyor that she had personally picked up all the trash around the dumpsters. The Dietary Manager agreed there should not be any trash on top of the dumpster lid, the dumpster lid should be closed, the dumpster should not be leaking, and there should not be trash on the ground. She revealed the free-standing water was always there after it rained, it settled there. An observation on 9/14/2023 at 5:30 p.m. when the survey team was leaving the conference room after the exit revealed the lid to one of the dumpsters was open.

Based on observations, record review, staff interviews, and review of the facility policies, titled LTC- Oxygen, and LTC Care Plan- Resident's Right to Participate, the facility failed to ensure that a care plan was developed for three of 29 sampled residents (R13, R23 and R61). Specifically, the facility failed to ensure R13 had a care plan that addressed the use of a foley catheter, failed to ensure there was a care plan that addressed oxygen use for R23, and failed to ensure that R61 had a care plan that addressed dialysis treatments that were utilized. Findings Include: Review of the facility policy titled, LTC- Oxygen dated 8/2023 revealed under Policy Subject: Oxygen 1. There must be a physician ' s order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered. 3. When the unit nurse initiates oxygen therapy for a resident, he/she must: a. guarantee the provider ' s order is populated to the TAR with modifications as needed. 7.The unit nurse must: e. administer medications, respiratory treatments, and oxygen as ordered by the resident ' s physicians or provider. 9. Oxygen tubing and/or masks must be replaced weekly and as needed. Review of the facility policy titled, LTC Care Plan- Resident's Right to Participate, dated 8/2023 under Policy and Procedure; Intent: it is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for and manage resident care as evidence by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team IDT, and will reflect the resident's initial strengths, limitations, and goals. 1.Review of the electronic medical record for R13, revealed that resident was admitted to the facility with diagnoses that included but were not limited to urinary tract infection, acute kidney failure, chronic diastolic heart failure, malignant neoplasm of the kidney, and obstructive and reflex uropathy. Review of the physician orders for R13 revealed that the resident is to have urinary catheter care on Monday, Wednesday, Fridays, and has a 16 French foley catheter in place. Review of the Admission MDS dated [DATE] revealed in Section C (Cognitive Patterns) resident had a BIMS score of 15, which means the resident is cognitively intact. Section H (Bladder and Bowel), that describes the resident's bladder and bowel function, revealed that the resident has an indwelling catheter. Observation on 9/12/2023 at 9:47am, R13 was resting in his bed with his eyes closed. The resident was observed with a foley drainage bag hanging from the bed frame. Observation on 9/13/2023 at 8:57am, R13 was observed resting in his bed, eyes open. The door was open and a foley drainage bag was observed hanging from the bed frame. It was observed with a privacy cover. Interview on 9/14/2023 at 8:23am with MDS Coordinator revealed that she is responsible for initiating and updating the care plan. She updates the care plan from information received from IDT meeting and morning meeting, care plan meetings on Tuesday, and post admission meeting. She revealed that indwelling catheters should be care planned. She also confirmed that R13 was admitted with a catheter, and she verified that it was not on his care plan. 2.Review of the electronic medical record for resident R23, revealed that he was admitted to the facility with diagnoses that included but are not limited to cerebral infarction, cognitive communication deficit, hypertension, disease of the pericardium, attention and concentration deficit, and dementia. Review of the physician orders for R23 revealed that he was ordered to have oxygen at 2 liters per minute, as needed to keep the residents oxygen saturation greater than 90 percent (%). Review of the readmission MDS dated [DATE] for R23 revealed Section C (Cognitive Patterns) that the resident has a Brief Interview for Mental Status (BIMS) score of 08, which means he is moderately cognitively impaired. Review of Section O (Special treatments and Programs) revealed that the resident used oxygen while not a resident and as a resident. Observation on 9/12/2023 at 9:23 am R23 was observed in a wheelchair dressed sitting in his room. He stated that he had just returned from having therapy. He was using oxygen at Two liters per minute via a nasal cannula. Observation on 9/13/2023 at 2:50 pm, R 23 was observed in his room, sitting in his wheelchair dressed, using oxygen at 2 liters per minute via a nasal cannula. Review of the care plan for R 23 revealed that there was no plan of care listed for respiratory and oxygen use. Interview on 9/14/2023 at 8:23 am with the MDS Coordinator, revealed that she is responsible for initiating and updating the care plan. She stated that she gets the information for updating from morning meeting, interdisciplinary team (IDT) meeting, care plan meeting on Tuesdays and admission care plan meeting that will occur within 5 days of admission. She verified that the care plan for R#23 did not have oxygen, that included amount and interventions. The resident was admitted using oxygen. She stated that oxygen use should be Care planned and she would update the care plan. 3. Review of the Electronic Medical Record (EMR) revealed medical diagnoses for R61 include but not limited to End Stage Renal Disease, Essential (Primary) Hypertension, Dependence on Renal Dialysis, and Anemia due to Chronic Kidney Disease. During a review of the Care Plan dated 5/22/2023 it was revealed there was no care plan initiated for Dialysis Treatment for R61. During a review of the Progress Notes, it was revealed on 5/22/2023 Resident arrived at facility and admitted into room [ROOM NUMBER]. She was admitted to the facility for End Stage Renal Disease, Diabetes Mellitus, Hypertension, and Alzheimer's; Dialyzed on Monday, Wednesday, Friday. Shunt noted to left arm with positive bruit/thrill. Interview on 9/14/2023 at 9:15 am with LPN GG revealed the Resident goes to Dialysis on Monday, Wednesday, and Friday; she eats breakfast before she leaves, she gets back around lunch time; vital signs are taken before she leaves and the staff at the Dialysis clinic will take the vital signs before she gets back; she has a shunt for dialysis, the nurses check it daily. The medication nurses do not initiate or update the care plans. Interview on 9/14/2023 at 10:15 am with the Minimum Data Set (MDS) Coordinator FF revealed she puts the care plan information in the computer; if there is a new admission the computer will generate a set of generic care plans automatically; after 48 hours there will be a meeting with the Resident and family and additional information can be added to the care plan. If there is a change in the Resident's condition the MDS nurse puts the information on the care plan. The nursing supervisor and DON can update the care plan; the medication nurse does not usually update the care plan. During the interview MDS Coordinator FF confirmed Dialysis was not listed on the Care Plan for R61. Interview on 9/14/2023 at 10:30 am with the Director of Nursing (DON) revealed that the MDS Coordinator puts the information on the care plan; she gets the information from the referral email and discharge orders; updates are discussed during the morning meeting. The Morning Meeting is held Monday through Friday; on the weekend there are nursing supervisors here so they can communicate with MDS about any changes. The DON confirmed Dialysis was not listed on the Care Plan for R61. 46579 48397

Based on observation, interview, and review of facility policies titled, LTC- Aerosol Administration and LTC- Oxygen. The facility failed to properly store respiratory equipment and ensure oxygen (02) was administered as ordered by the physician for two (2) of nine (9) residents (R) (R22 and R28). Specifically, the facility failed to ensure R22 humidifier bottle was changes according to the physicians order, the facility also failed to ensure the nebulizer mask for R28 was stored and labeled properly, deficient practice had the potential to increase the probability of R22 and R28 contracting a Respiratory infection. Findings include: Review of the facility policy titled, LTC- Aerosol Administration last revised 11/2021 revealed under Purpose: To deliver aerosol medications to restore and maintain normal function of the mucociliary escalator, improve efficiency of cough mechanism, provide bronchodilator therapy, and deliver other medications to the airway. 6. Empty any residual liquid and place the nebulizer on a plastic patient bag. Review of the facility policy titled, LTC- Oxygen last revised 8/2023 revealed under Policy Subject: Oxygen 9. Oxygen tubing and/or mask must be replaced weekly. Observation on 9/12/2023 at 10:36 am revealed R28 nebulizer mask was not bagged and not labeled, nor dated. Record review for R28 revealed diagnoses that included: Pneumonia, other disorders of lung, chronic obstructive pulmonary disease with (acute) exacerbation, dependence on supplemental oxygen. Observation on 9/12/2023 10:45 a.m. revealed R22 oxygen concentrator was on 1.5 Litters per minute (L/M) and date on the water bottle was 9/5/2023. Record review for R22 revealed diagnoses included: chronic obstructive pulmonary disease, unspecified, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation. Review of the physician orders revealed Change tubing at least every 72 hours, every week clean oxygen tubing weekly and prn, provide new bag with initials and date. Change nebulizer tubing weekly and prn (as needed). Observation on 9/13/2023 at 8:14 am revealed R22 O2 concentrator is on and it ' s turned to 1.5L, water is dated 9/5/23 with water in it. Interview on 9/13/2023 at 3:41 pm with Director of Nursing (DON) revealed nebulizers should be bagged and dated. DON confirmed Nebulizer mask was sitting on top of machine without a bag.

Based on record review and staff interviews, the facility failed to implement the plan of care for one resident (R) R#1 with a known history of elopement, to perform frequent location checks of exit seeking behavior from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. The noncompliance related to the IJ was identified to have existed on 5/16/23. An Acceptable IJ Removal Plan was received on 6/9/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/9/23. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: schizophrenia, major depressive disorder, acute encephalopathy, hypertension, schizoaffective disorder, auditory and visual hallucinations, diabetes mellitus type II, bipolar, communication impairment, neurological muscle weakness, risk of elopement from cognitively impaired subject, and wandering. The resident had a Quarterly Minimum Data Set assessment completed on 4/24/23 indicating a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior, independent for transfers, and supervision with ambulation. The resident had a care plan since 11/22/21 for elopement behaviors managed to prevent harm, wanders at night and history of opening windows or checking to see if doors are locked with the following interventions: perform frequent location checks if exit seeking behavior and utilize Wander Alert device. There was also a physician's order since 11/5/21 to monitor resident for exit seeking behaviors six times per day following 9/29/21 incident (eloped from facility). Review of the Safety Checks TAR revealed the resident was not monitored for exit seeking behaviors six times a day as ordered by the physician. The document revealed on 5/8/23 monitored twice, 5/9/23 and 5/10/23 monitored three times, 5/11/23 monitored twice, 5/12/23 and 5/13/23 monitored once, 5/14/23 monitored twice, and 5/15/23 monitored once. On 5/16/23 staff documented they monitored the resident at 1:41 p.m. and at 5:44 p.m. although the resident had already eloped from the facility. During an interview with LPN AA on 5/30/23 at 1:35 p.m. she stated she checked the resident's blood sugar on 5/16/23 around 11:00 a.m. or 11:30 a.m. and last saw the resident between 11:30 a.m. or 12:00 p.m. walking around Station 2 where his room was. She stated she made up the resident's blood sugars and falsified the documentation. At 4:30 p.m. she to look for the resident to check his blood sugar but she did not see him in his room, and she didn't even think to go and look for him, she just continued to go and check other resident's blood sugars. She stated she was supposed to do two-hour checks on her residents, but she was so far behind that day. She also stated that none of the staff had reported the resident's meal trays being untouched to her. During an interview with CNA BB on 5/25/23 at 4:55 p.m., she stated she last saw the resident on 5/16/23 around 11:30 a.m./12:00 p.m. when she was passing out lunch trays. She stated that she thought an agency CNA had delivered the resident's supper tray later that day. She stated that she was new to this and had gotten her CNA certification in April 2023 and she did not realize she was supposed to make rounds every two hours on the residents. There was no evidence the facility staff performed the frequent location checks on 5/16/23 as outlined in the care plan which resulted in the resident being missing for approximately eight hours before staff realized the resident had eloped from the facility. The resident was not found until nearly 21 hours later under an overpass on I-75 approximately 2.5 miles from the facility. The facility implemented the following actions to remove the IJ: (1) Resident # 1 is currently residing at Crisp Regional Health and Rehab and continues to have routine consults with the MD. His care plan was reviewed and revised on 5/17/2023 and 6/6/2023 by the Lead MDS to reflect the current elopement status high risk. Hourly rounds are being performed and wanderguard safety checks daily as indicated on the care plan. (2) On 05/17/2023, the policy for Elopement and LTC Care Plans were reviewed by the Administrator, LTC Quality Administrator, VP of LTC, and MDS Lead with no revisions made. The Medical Director reviewed and approved the Elopement Policy on 6/8/2023. (3) On 05/17/2023 and again on 06/06/2023, the MDS lead reviewed elopement care plans on 60 of 60 residents. There are 6 residents out of 60 residents identified at high risk for elopements. The care plans were updated to reflect all elopement interventions and the assessment questions as reflected in the LTC Elopement Policy. (4) On 06/07/2023, the Lead MDS in-serviced the IDT, which consists of SSD, MDS nurse, Unit Managers, Dietary Manager, Activity Director, Rehab Director, Wound Nurse, Admissions Director, Infection Control Nurse, Medical Records Director, Maintenance Director, and Administrator on development/ implementation of Elopement Care Plans. (5) On 06/06/2023, the Lead MDS implemented a Hourly Elopement Risk Rounding tool to audit residents identified as high risk for elopements with every 1-hour rounding, 24 hours 7 days/week. This audit includes wander guard system checks daily which includes testing the wanderguard bracelet to guarantee when in the vicinity of the (2) functioning door, the alarm sounds and locks appropriately. (6) On 6/6/2023 The MDS Lead implemented an Elopement Book at each nurse's station, inclusive of the Elopement Policy, all high risk for elopement resident profiles, pictures and care plans for easy access to all staff. All staff (10 of 10 RNs, 12 of 12 LPNs, 25 of 25 CNAs, 5 dietary, 1 of 1 materials management, 2 of 2 of maintenance, 6 of 6 housekeeping, 4 of 4 Therapists, 1 of 1 SSD, 1 of 1 BOM, 5 of 5 agency CNAs, and 5 of 5 agency LPNs, totaling 77 employees) have been educated where to access the elopement care plans by the RN MDS Lead and RN QA Nurse between 6/6/23 - 6/8/23. The remaining 18 PRN employees will be in-service prior to the next shift worked by the RN Nurse Educator, MDS Lead, Clinical Coordinator and/or Director of Nursing. (7) The Administrator and/or Director of Nursing will review the results of the audits daily starting 6/8/2023 to determine compliance. If a deficient practice is identified, it will be corrected immediately in an ADHOC QAPI and reviewed monthly in QAPI. (8) On 6/7/2023 the Quality Nurse implemented an Elopement Risk QAPI Audit Tool inclusive of the following that will be reported at each QAPI meeting: a. Number of elopement attempts, resident that attempted elopement, interventions put in place and care-plan review. b. Any residents exhibiting new exit seeking behaviors, interventions put in place and care-plan review. c. Audit that all required Elopement assessments are complete in correlation with new admissions, changes in condition and quarterly as indicated by the MDS assessment schedule. (9) An ADHOC QAPI meeting was held 5/26/2023 reviewing the elopement event that took place and the interventions in place. A second ADHOC QAPI meeting related to the incident was held 6/7/2023 to review the monitoring and audit tools implemented including the Hourly Elopement Risk Tool and the QAPI Elopement Risk Audit Tool. (10) Date corrective action will be completed is 6/8/2023 and IJ to be removed on 6/9/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: (1) R#1 remains as a resident at the facility and this was verified via review of facility census data, dated 6/11/23 and review of R#1's clinical record, which included R#1's elopement risk care plan. Review of the Hourly Elopement Risk Rounding forms from 5/17/23 through 6/11/23 revealed that hourly rounds and daily wander guard safety checks were being completed by staff. This information was further verified via interview with the Administrator on 6/13/23 at 11:18 a.m. (2) Review of the LTC Elopement Policy with revision date of 6/2023 was verified. The policy included care plan procedures related to elopement. The policy was signed by the facility CEO, Director/VP of LTC, and the LTC Quality Administrator. A typed and signed statement, dated 6/8/23 from the Medical Director confirmed his agreement with the LTC Elopement plan. Also verified via interviews on 6/12/23 at 11:27 a.m. with the MDS Lead, on 6/13/23 at 11:18 a.m. with the Administrator, and on 6/13/23 at 12:20 p.m. with the LTC Quality Administrator. (3) Review of the elopement risk score sheets revealed they were completed on all residents on 5/17/23 and again on 6/6/23. A review of the elopement risk score sheets revealed that the initial six residents identified at high risk for elopement on 5/17/23 were R#1, R#2, R#3, R#4, R#5 and R#7. An additional resident, R#6, was also identified as high risk for elopement on 6/7/23. During an interview on 6/12/23 at 2:45 p.m. the DON confirmed the residents identified as being high risk for elopement and stated that monitoring of R#7 stopped, and he was no longer high risk, due to a change in condition. R#6 was a new admission on 6/7/23. Review of the care plans for R#1, R#2, R#3, R#4, R#5, R#6, and R#7 revealed they were updated to include elopement risk and interventions. (4) Review of In-service education information titled Elopement IPOC's/Care-Plans with the accompanying staff signature sheets, dated 6/7/23 confirmed education provided to IDT. Also verified via interviews on 6/13/23 at 11:18 a.m. with the Administrator and at 11:45 a.m. with the Infection Control Nurse. Confirmed via interview with the Lead MDS on 6/12/23 at 11:27 a.m. she in-serviced the IDT team on the development/implementation of elopement care plans. Staff interviews conducted on 6/12/23 at 11:23 a.m. with Activities Director DD, at 11:40 a.m. with MDS coordinator GG, at 11:45 a.m. with Unit Manager HH, at 12:14 p.m. with the Medical Records Director, at 12:34 p.m. with the SSD and at 2:00 p.m. with the Dietary Manager and on 6/13/23 at 10:43 a.m. with the Maintenance Director confirmed they had received the in-service on the development/implementation of elopement care plans. (5) Record review of the Hourly Elopement Risk Rounding tools confirmed completed on all residents identified as high risk for elopements. Also verified via review of the QAPI Elopement Risk audit tools completed by the Administrator from 6/8/23 through 6/12/23. Interview with the Lead MDS on 6/12/23 at 11:27 a.m. who reported that she implemented the Hourly Elopement Risk Rounding tool for residents identified as high risk for elopement. (6) During an interview on 6/12/23 at 11:55 a.m., the RN QA Nurse (who is also the RN Nurse Educator) verified that the in-service education had been completed with all full-time facility staff (in person and/or over the phone) and that the 18 remaining PRN staff would be in-serviced prior to the next shift worked. She stated that she completed the in-service education with day shift staff and the MDS Lead completed in-service education with night shift staff. Review of the in-service education information and staff signature sheets titled Compliance and Ethics, IC P&P, Elopement Policy/IPOC, dated 6/6/23 through 6/8/23 revealed that 10 RN's, 12 LPN's (including 5 agency LPN's), 25 CNA's (including 5 agency CNA's), 5 dietary staff, 1 materials management staff, 2 maintenance staff, 6 housekeeping staff, 4 therapy staff, 1 SSD, and 1 BOM received the in-service education. Staff interviews conducted on 6/12/23 at 11:10 a.m. with CNA CC, at 11:23 a.m. with the Activities Director, at 11:25 a.m. with CNA EE, at 11:36 a.m. with Rehab Tech FF, at 11:40 a.m. with MDS Coordinator GG, at 11:45 a.m. with RN, Unit Coordinator HH, at 11:52 a.m. with Business Office Manager, at 11:55 a.m. with Infection Control, QAPI Nurse and Education Nurse, at 12:07 p.m. with CNA II, at 12:11 p.m. with LPN JJ, at 12:14 p.m. with Medical Records Director, at 12:17 p.m. with CNA KK, at 12:21 p.m. with LPN LL, at 12:34 with the SSD, at 12:57 p.m. with PTA MM, at 1:00 p.m. with HK/Floor Tech NN, at 1:04 p.m. with RN Weekend Supervisor OO and LPN PP, at 1:06 p.m. with the HK Manager, at 1:10 p.m. with Therapy/Office QQ, at 1:15 p.m. with CNA RR, at 1:23 p.m. with Respiratory Therapist SS, at 1:35 p.m. with Vent Unit Coordinator/RT TT, at 1:52 p.m. with HK UU and Vent Unit RN VV, at 1:55 p.m. with HK/Laundry WW, at 2:00 p.m. with the DM and HK XX, at 2:21 p.m. with Dietary Aide YY, at 2:24 p.m. with CNA BB, at 2:25 p.m. with Dietary ZZ, at 2:45 p.m. with the DON, at 3:03 with HK AAA, at 4:24 p.m. with CNA BBB, at 4:35 p.m. with CNA CCC, at 4:37 p.m. with LPN DDD, on 6/13/23 at 9:20 a.m. with LPN FFF, at 9:27 a.m. with CNA GGG, at 9:30 a.m. and at 10:43 a.m. with the Maintenance Director confirmed they had received in-service training on the Elopement books, Elopement Policy, Elopement resident profiles and care plans. (7) Verified via review of the QAPI Elopement Risk Audit Tools signed and dated 6/8/23 through 6/12/23 by the Administrator. The completed audit tools included all residents identified as high risk for elopement. During an interview on 6/13/23 at 11:18 a.m. the Administrator confirmed completion of the tools and review of the results. (8) Verified via review of the QAPI Elopement Risk Audit Tool which included the categories of elopement attempts, residents exhibiting exit seeking behaviors, elopement assessments, hourly elopement risk and wander guard safety check audit. During an interview on 6/12/23 at 11:55 a.m. the Quality Nurse confirmed the use of the tool and that the results of the audits would be discussed at the next QAPI meeting scheduled for 6/30/23. (9) Verified via review of the QAPI signature sheet, dated 5/26/23 and the accompanying QAPI meeting information, which included the topic of elopement and elopement POC. Also verified via review of the QAPI ADHOC meeting information and accompanying staff signature sheet, dated 6/7/23. The agenda included elopement and the audit tools implemented. Also verified via review of the Elopement PIP accepted by the QA committee on 6/7/23. During an interview on 6/13/23 at 11:45 a.m., the Quality Nurse confirmed the meetings were held on 5/26/23 and 6/7/23 and included discussions on elopement, interventions in place, and use of the monitoring and audit tools. She stated the next QAPI meeting was scheduled for 6/30/23. During an interview on 6/13/23 at 11:18 a.m., the Administrator also confirmed the QAPI meetings and elopement discussion. (10) All corrective actions were corrected on 6/8/2023 and the immediacy of the IJ was removed on 6/9/23.

Based on staff interviews, record review, and review of the facility policy titled, Elopement, the facility failed to provide adequate supervision and frequent monitoring of resident (R) #1 and failed to ensure one of three doors equipped with the Wander Guard system was functioning to prevent the elopement of one resident R#1 from a sample of eight residents. On 6/5/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Infection Preventionist were informed of the Immediate Jeopardy (IJ) on 6/5/23 at 1:00 p.m. The noncompliance related to the IJ was identified to have existed on 5/16/23. An Acceptable IJ Removal Plan was received on 6/9/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/9/23. Findings include: Review of the facility policy titled Elopement with a revision date of 11/2021 revealed the following: Residents who wander are considered an elopement risk, and the facility will ensure that the safety of residents who wander is maintained, and that elopement is prevented; All of the unit's staff members are aware which residents are an elopement risk and are familiar with their care plans; All of the unit's staff members are familiar with the plan of action in the event of a resident elopement; If a resident tries to follow a staff member through the door of a locked unit, the staff member should reverse direction, and then distract to prevent the resident feeling locked in or confined. R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: schizophrenia, major depressive disorder, acute encephalopathy, hypertension, schizoaffective disorder, auditory and visual hallucinations, diabetes mellitus type II, bipolar, communication impairment, neurological muscle weakness, risk of elopement from cognitively impaired subject, and wandering. The resident had a Quarterly Minimum Data Set assessment completed on 4/24/23 indicating a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, having no behaviors or wandering behavior, independent for transfers, and supervision with ambulation. The resident had a care plan since 11/22/21 for elopement behaviors managed to prevent harm, wanders at night and history of opening windows or checking to see if doors are locked with the following interventions: perform frequent location checks if exit seeking behavior and utilize Wander Alert device. The resident had an elopement risk score of 75 on 5/2/23 indicating the resident was at risk for elopement. The assessment also indicated the resident had a history of elopement attempts, wandering, was independent with mobility and had impaired short-term memory. There was also a Physician's order since 11/5/21 to monitor resident for exit seeking behaviors six times per day following 9/29/21 incident (eloped from facility). Review of the Safety Checks TAR revealed the resident was not monitored for exit seeking behaviors six times a day as ordered by the physician on the following dates: on 5/8/23 monitored twice, 5/9/23 and 5/10/23 monitored three times, 5/11/23 monitored twice, 5/12/23 and 5/13/23 monitored once, 5/14/23 monitored twice, 5/15/23 monitored once, 5/16/23 staff documented they monitored the resident at 1:41 p.m. and at 5:44 p.m. although the resident had already eloped from the facility. Review of the Wander Guard Functioning Log Weekly Check forms revealed the Wander Guard was checked weekly and was last checked on 5/8/23 prior to 5/16/23. However, the documentation did not include which doors were checked that were equipped with the Wander Guard system. During an interview with the Maintenance Supervisor on 5/24/23 at 3:35 p.m., he stated three doors are equipped with the Wander Guard system and he only checks one of the three doors each week by walking R#1 up to the door. He stated the front door was last checked three weeks prior to the elopement incident on 5/16/23 and was working at that time. On 5/18/23 at 2:23 p.m. observations were made with the Maintenance Supervisor of the three doors equipped with the Wander Guard system by walking R#1 up to each door. During this observation the front door alarm did not sound when R#1 walked out the door. Review of the 5/17/23 2:46 a.m. Progress Notes documented that at 8:20 p.m. on 5/16/23 staff was looking for resident to administer p.m. medications and activities of daily living (ADL) care. The resident was not in his room. The writer then proceeded to call station one to see if the resident went to visit that side of the building. The resident was not located. The family was called at 8:40 p.m. to see if relatives had come to get him for a home visit. All in house staff searched building, every room from 8:40 p.m.- 9:15 p.m. The resident was not located. At 9:31 p.m. notified facility on call nurse who then contacted the Director of Nursing (DON) and received orders at 9:39 p.m. to notify family and 911 and follow Elopement policy. Elopement alert went out to all day shift nurses and managers at 9:40 p.m. 911 arrived at facility at 10:25 p.m. All staff and 911 proceeded to search premises, additional staff searched on and off premises and surrounding neighborhood in personal vehicles. Two Certified Nursing Assistants (CNA) searched east and west areas of neighborhood. Available staff, social worker, Administrator, Human Resources Administrator, Maintenance Supervisor along with 911 searched for resident in different areas. Resident has not been located. Silver alert broadcasted at 1:29 a.m. The Nursing Narrative Note dated 5/17/23 at 11:00 a.m. indicated the DON was alerted by authorities that R#1 was observed to be outside near facility. Emergency Medical Services (EMS) picked resident up and all vitals were within normal limits upon initial assessment. Resident stated he felt fine and was laying down when observed initially. EMS stated resident jumped up and started walking without difficulties. Resident drank two Gatorades given by EMS. Resident returned to facility via EMS at 10:00 a.m. Vitals were obtained: 129/57, 103, 97.6, 18 and 97% on room air. Blood sugar was 217. Stat labs were drawn as ordered by physician. At 10:15 a.m. resident had a skin assessment completed and a bath was given. At 10:45 a.m. the Physician and Nurse Practitioner did an evaluation of the resident with no new orders. Resident was given a tray and ate 100%. Resident was resting in his room following his meal. Review of the 5/17/23 Nurse Practitioner progress note revealed the resident was seen secondary to elopement yesterday. Patient was seen and evaluated with physician with patient being in no acute distress. Status post elopement this gentleman who was found under exit 104 bridge, returned by EMS in no acute distress. Review of the 5/16/23 local Sheriff's Office Incident Report revealed the Deputy was dispatched to the facility on [DATE] at 10:15 p.m. and was advised by staff that one of the patients was missing. The Deputy reviewed the camera system but was unable to pinpoint exactly where R#1 left the building due to some of the cameras not having video and some of the videos skipping. He was able to locate the resident on video at 12:30 p.m. near the front nurse station. The deputy spoke to staff that identified herself as the [NAME] President of the facility and told the deputy that she had contacted the employee that was responsible for checking the resident's blood sugar. She stated she found out her employee had lied about checking R#1's blood sugar at 4:30 p.m. She reported the last time anyone at the facility accounted for R#1 was at 12:30 p.m. Review of the timeline for 5/16/23-5/17/23 provided by the Administrator revealed the following: 5/16/23- 8:00 p.m. LPN arrived 8:20 p.m.- LPN began to give medications and could not find the resident. 8:40 p.m. called resident's sister who stated the resident was not with her. 9:00 p.m.- CNA was looking resident in his room and observed the lunch and dinner trays were still in his room. 9:41 p.m.- on call nurse informed of elopement. 9:43 p.m.- DON called the Administrator. 9:44 p.m.- informed nurse to initiate plan. 9:45 p.m.- called LPN AA who initially stated she checked the resident's blood sugar at 3:30 p.m. She then came back and admitted she did not check his blood sugar and had not laid eyes on him since 12:00 p.m. LPN AA documented she checked the blood sugar and administered glimepiride on the Medication Administration Record (MAR) at 5:44 p.m. 9:52 p.m.- called CNA BB who last saw resident in his room at lunchtime and walking around. 10:00 p.m.- search crew. 10:19 p.m.- hospital called to see if resident was there. 10:30 p.m.- address of sister received, resident not there. Police arrive to facility. Resident was noted to have left at 12:37 p.m. on 5/16/23 with transport company 5/17/23 at 9:45 a.m. resident was found. EMS returned resident to the facility at 10:00 a.m. Review of the typed statement from the transportation personnel dated 5/19/23 noted the transportation staff documented on 5/16/23 after 12:00 p.m. he was at the facility when he observed R#1 walk out of the front door on the north side of the nursing home near station one. Review of the active physician's orders revealed the following orders: - Blood glucose monitoring four times a day before meals and bedtime with sliding scale insulin - Novolog 70/30 insulin 26 units twice a day - glimepiride (oral diabetes medicine) 4 milligrams (mg) twice a day with meals Review of the May 2023 Medication Administration Record (MAR) revealed LPN AA falsified documentation by documenting she administered glimepiride 4mg on 5/16/23 at 5:44 p.m., and documented she checked the resident's blood glucose at 1:41 p.m. and at 5:44 p.m. although the resident was not in the facility at those times. Further review of the May 2023 MAR revealed the resident had missed the scheduled Novolog 70/30 insulin scheduled for 5/16/23 at 9:00 p.m., scheduled blood glucose monitoring at 9:00 p.m. and the blood glucose monitoring scheduled for 5/17/23 at 8:00 a.m. due to the resident eloping from the facility on 5/16/23 around 12:30 p.m. putting him at risk for a hypo/hyperglycemic episode. During an interview with LPN AA on 5/30/23 at 1:35 p.m. she stated she checked the resident's blood sugar on 5/16/23 around 11:00 a.m. or 11:30 a.m. and last saw the resident between 11:30 a.m. or 12:00 p.m. walking around Station two where his room was. She stated she made up the resident's blood sugars and falsified the documentation. LPN AA reported that on 5/16/23 at 4:30 p.m. she looked for the resident to check his blood sugar but she did not see him in his room and she didn't even think to go and look for him, so she just continued to go and check other resident's blood sugars. She stated she was supposed to do two-hour checks on her residents but she was so far behind that day. She also stated that none of the staff had reported the resident's meal trays being untouched to her. During an interview with CNA BB on 5/25/23 at 4:55 p.m., she stated she last saw the resident on 5/16/23 around 11:30 a.m./12:00 p.m. when she was passing out lunch trays. She stated that she thought an agency CNA had delivered the resident's supper tray later that day. She stated that she was fairly new to this and had gotten her CNA certification in April 2023 and she did not realize she was supposed to make rounds every two hours on the residents. Review of the LPN nurse job description noted the following essential job responsibilities: Effectively and consistently performs basic nursing skills and treatments as prescribed by the physician or as indicated by the patient's condition, Provides assigned patients with quality patient care services consistent with the standards of care established by Nursing Services and the named facility, Documents patient care which reflects appropriate nursing interventions and includes evidence of appropriate patient/family education, Performs associated duties, responsibilities, and tasks relating to safety, infection control, and performance improvement as part of the named facility's efforts to provide quality care and services, Performs rounds every two hours for the purpose of providing quality care and services. Review of the Certified Nursing Assistant Job Description noted the following essential job responsibilities: Alerts the nursing staff and medical staff to observed changes in the patient's condition, Complies with the named facility and developmental safety, infection control, and performance improvement initiatives to ensure the delivery of quality care and services, Performs rounds every two hours for the purpose of providing quality care and services and performs other related job duties as assigned to assure resident safety. During an interview with the DON on 5/31/23 at 11:45 a.m., she stated she does expect staff to make rounds every two hours on the residents and to do a location check on R#1. During an interview with the Administrator on 5/18/23 at 11:15 a.m., she stated that they determined that on 5/16/23 sometime after 12:00 p.m., the resident followed transportation staff out the front door. The transportation person thought the resident was allowed to go out. The staff did not determine the resident was missing until the night shift nurse came on duty and went to give the resident his medications. Day shift had delivered the resident's lunch tray and left it in his room. They then delivered his supper tray and noticed the lunch was untouched but did not look for the resident. They called the Sheriff's department and the police department and had staff from the facility and the hospital looking for the resident all night. He was found the next morning when his cousin was driving down I-75 and saw the resident under the bridge overpass. The resident was assessed by EMT's and brought back to the facility where R#1 was assessed by facility staff. There were no injuries, and his blood sugar was stable. She stated when the EMT's brought the resident back in through the front door they realized the Wander Guard system did not alarm when he came through the front door. Once they identified the front door alarm was not working, they placed staff at the desk at the front door at all times until a new system is installed. The facility implemented the following actions to remove the IJ: (1) Resident #1 is currently residing at Crisp Regional Health and Rehab and continues to have routine consults with the MD. The following interventions were immediately put in place upon his return to the facility: head to toe assessment with no injuries, vital signs and lab work all within normal limits, resident bathed and changed, skin assessment completed, hourly rounds implemented, and daily wanderguard safety checks implemented. No additional elopement have occurred since the incident. (2) The LPN AA responsible for this resident was suspended pending investigation on 5/17/2023 and submitted her resignation on 5/18/2023. The LPN AA license was reported to the licensure board on 5/19/2023. The CNA BB responsible for the resident was suspended pending investigation on 5/17/2023. The CNA BB received education on 5/25/23 regarding rounding on residents, rounding on elopement risk residents, proper timely reporting of residents that have not been seen when performing rounds, as well as the Code Pink Missing Person protocol. The CNA BB received a written corrective disciplinary action on 5/24/23 that will be reviewed on. (3) On 5/17/2023 100% audit of all current residents (60 total) completed by the SSD. 6 residents were identified as high-risk for elopement and placed on hourly rounding by nursing staff. The Hourly Rounding Elopement Risk Tool is being utilized to document hourly rounds by staff. This tool is also being reviewed daily by the Administrator and/or DON Monday - Friday, and the RN supervisor, Director of Nursing and/or Clinical Coordinator Saturday - Sunday. (4) The front door Wanderguard alarm system was identified as ineffective on 5/16/2023, therefore the door has been manned 24 hours/day 7 days/week since and will continue to be until the Wanderguard system is replaced. Approval received for the replacement of the Wandergaurd system upgrade was received on 05/22/2023. Once the equipment is received, the upgrade date will be established. There is 1 entrance/exit door that is not working properly and must be manned 24 hours/day, 7 days/week. There are 3 total Wanderguard entrance/exit doors. If another Wanderguard entrance/exit door stops working properly, the facility will staff the door 24 hours/day 7 days/week. (5) On 5/17/2023 the policy for Elopement and LTC Care Plans were reviewed by the Administrator, LTC Quality Administrator, VP of LTC, and MDS Lead with no revisions made. The Medical Director reviewed and approved the Elopement Policy on 6/8/2023. (6) In-service education for the Elopement Policy and procedures was initiated on 05/17/2023 with completion on 05/23/2023 as well as 6/6/2023 with completion of 6/7/2023. Education was provided by RN Quality Nurse and or MDS Lead to 10 of 10 RNs, 12 of 12 LPNs, 25 of 25 CNAs, 5 of 5 dietary, 1 of 1 materials management, 2of 2 maintenance, 6 of 6 housekeeping, 4 of 4 Therapists, 1 of 1 SSD, 1 of 1 BOM, 5 of 5 agency CNAs, and 5 of 5 agency LPNs, totaling 77 employees were educated on facility Elopement policy and procedures. This is 100% of full time employees. (7) No staff shall work until they have completed the Elopement policy and procedures in-service education. There are 0 staff members that are part time, and 18 staff members that are PRN. These staff members will be in-serviced by the RN Quality Nurse, MDS Lead, Clinical Coordinator and/or Director of Nursing. (8) Newly hired staff will be in-serviced prior to first day on the floor by the RN Quality Nurse, MDS Lead and/or Director of Nursing. No new staff shall work without first receiving education on the elopement policy. (9) Facility implemented interventions on 05/17/2023 which included front entrance/exit manned 24 hours/day 7 days/week, Wandergaurd elopement education, census rounding each shift, 1 hour rounding on high risk residents. On 6/6/2023 elopement books and daily Wanderguard safety checks were implemented for the 2 functioning Wanderguard entrance/exit doors. There are 3 total Wanderguard entrance/exit doors in the facility. (10) New interventions will be monitored by the IDT team to include the Administrator and the DON daily. These interventions will be audited utilizing the QAPI Elopement Audit Tool until 100% compliance is achieved for 6 consecutive months; random audits will continue thereafter. If a deficient practice is identified, it will be addressed in ADHOC QAPI and reviewed monthly in QAPI. (11) Date corrective action will be completed is 6/8/2023 and IJ to be removed on 6/9/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: (1) Verified via review of R#1's clinical record including the 5/17/23 bath sheet documentation, 5/17/23 skin assessment, 5/17/23 nurses' notes entries and 5/17/23 laboratory results. Hourly rounds and daily wander guard safety checks for R#1 were verified via review of the Hourly Elopement Risk Rounding Forms completed from 5/17/23 through 6/11/23. On 6/13/23 at 11:45 a.m. R#1 was observed in the facility walking and redirected when walking towards the doors. (2) LPN AA's suspension and resignation were confirmed via review of the 5/17/23 employee write-up information and Payroll Status Change form that documented LPN AA was removed from payroll on 5/17/23. During an interview on 6/13/23 at 10:20 a.m., the Administrator confirmed that LPN AA resigned on 5/18/23. The Administrator also confirmed that she reported LPN AA to the state nursing board on 5/18/23. CNA BB's suspension, re-education, and written corrective disciplinary action were confirmed via review of the Employee Counseling/Disciplinary Action Notices dated 5/17/23 and 5/24/23 that documented the initial suspension and subsequent written warning. Also verified via review of the education information signed by CNA BB and dated 5/25/23. During an interview on 6/12/23 at 2:24 p.m. CNA BB confirmed the suspension, written warning, and education she received. (3) Verified via review of the elopement risk score sheet lists, that documented elopement risk scores on all residents, on 5/17/23 and 6/7/23. A review of the elopement risk score sheet lists revealed that the initial six residents identified as high risk for elopement on 5/17/23 were R#1, R#2, R#3, R#4, R#5 and R#7. An additional resident, R#6, was also identified as high risk for elopement on 6/7/23. During an interview on 6/12/23 at 2:45 p.m., the DON confirmed the residents identified as being high risk for elopement and stated that monitoring of R#7 stopped because he was no longer high risk, due to a change in condition. R#6 was a new admission on 6/7/23. Review of Hourly Elopement Risk Rounding Tools completed from 5/17/23 through 6/11/23 revealed that hourly rounding was being completed on all residents identified as high risk for elopement. During an interview on 6/13/23 at 11:18 a.m. the Administrator confirmed review of the forms. Confirmed through interview with the SSD on 6/12/23 at 12:34 p.m. she completed a 100% audit of all 60 residents and identifying six residents as high-risk for elopement and placed on hourly rounding by nursing staff. (4) Monitoring of the front door was verified via observations on 6/12/23 at 9:30 a.m. and 6/13/23 at 9:05 a.m. of a staff person stationed in the front lobby, monitoring the front door. Also verified via review of the Employee Sitter Logs for the front door from 5/17/23 through 6/12/23. Approval and pending installation of a new wander guard system upgrade was verified via review of the 5/22/23 proposal and 5/25/23 signed approval (by the CEO) and 5/26/23 purchase order for a Rome Alert System. During an interview on 6/13/23 at 11:18 a.m., the Administrator confirmed purchase of the new wander guard system and stated that the equipment had shipped on 6/12/23 and would be installed once received. (5) Verified via review of the LTC Elopement Policy with revision date of 6/2023. The policy included care plan procedures related to elopement. The policy as signed by the facility CEO, Director/VP of LTC, and the LTC Quality Administrator. A typed, signed statement, dated 6/18/23 from the Medical Director confirmed his agreement with the LTC Elopement plan. Also verified via interviews on 6/12/23 at 11:27 a.m. with the MDS Lead, on 6/13/23 at 11:18 a.m. with the Administrator, and on 6/13/23 at 12:20 p.m. with the LTC Quality Administrator. (6) During an interview on 6/12/23 at 11:55 a.m., the RN Quality Nurse (who is also the RN Nurse Educator) verified that the in-service education had been completed with all full-time facility staff (in person and/or over the phone) and that the 18 remaining PRN staff would be in-serviced prior to the next shift worked. Review of the in-service education information and staff signature sheets titled Elopement policy/missing resident education and hourly rounds/documentation (dated 5/17/23), Elopement policy/Missing resident (dated 5/22/23), and Compliance and Ethics, IC P&P, Elopement Policy/IPOC (dated 6/6/23-6/8/23) revealed that 10 RN's, 12 LPN's (including 5 agency LPN's), 25 CNA's (including 5 agency CNA's), 5 dietary staff, 1 materials management staff, 2 maintenance staff, 6 housekeeping staff, 4 therapy staff, 1 SSD, and 1 BOM received the in-service education. Staff interviews conducted on 6/12/23 at 11:10 a.m. with CNA CC, at 11:23 a.m. with the Activities Director, at 11:25 a.m. with CNA EE, at 11:36 a.m. with Rehab Tech FF, at 11:40 a.m. with MDS Coordinator GG, at 11:45 a.m. with RN, Unit Coordinator HH, at 11:52 a.m. with Business Office Manager, at 11:55 a.m. with Infection Control, QAPI Nurse and Education Nurse, at 12:07 p.m. with CNA II, at 12:11 p.m. with LPN JJ, at 12:14 p.m. with Medical Records Director, at 12:17 p.m. with CNA KK, at 12:21 p.m. with LPN LL, at 12:34 with the SSD, at 12:57 p.m. with PTA MM, at 1:00 p.m. with HK/Floor Tech NN, at 1:04 p.m. with RN Weekend Supervisor OO and LPN PP, at 1:06 p.m. with the HK Manager, at 1:10 p.m. with Therapy/Office QQ, at 1:15 p.m. with CNA RR, at 1:23 p.m. with Respiratory Therapist SS, at 1:35 p.m. with Vent Unit Coordinator/RT TT, at 1:52 p.m. with HK UU and Vent Unit RN VV, at 1:55 p.m. with HK/Laundry WW, at 2:00 p.m. with the DM and HK XX, at 2:21 p.m. with Dietary Aide YY, at 2:24 p.m. with CNA BB, at 2:25 p.m. with Dietary ZZ, at 2:45 p.m. with the DON, at 3:03 with HK AAA, at 4:24 p.m. with CNA BBB, at 4:35 p.m. with CNA CCC, at 4:37 p.m. with LPN DDD, on 6/13/23 at 9:20 a.m. with LPN FFF, at 9:27 a.m. with CNA GGG, at 9:30 a.m. and at 10:43 a.m. with the Maintenance Director confirmed they had received in-service training on the Elopement books, Elopement Policy, Elopement resident profiles and care plans. (7) During interviews on 6/12/23 at 11:55 a.m. and 6/13/23 at 11:45 a.m., the RN Quality Nurse confirmed that the facility had no part-time staff and the 18 PRN staff members would be in-serviced prior to the next shift worked. (8) During an interview on 6/13/23 at 11:45 a.m. the RN Quality Nurse confirmed that no new staff shall work without first receiving education on the elopement policy. She stated that the facility did not currently have any newly hired staff. (9) All of interventions were verified via observations, interviews and record reviews previously stated at above at numbers 1-8. (10) During an interview on 6/13/23 at 11:18 a.m., the Administrator confirmed that elopement interventions would continue to be audited and reviewed until 100% compliance is achieved for 6 consecutive months and any deficient practice identified would be addressed with an ADHOC QAPI meeting. During an interview on 6/13/23 at 11:45 a.m., the Quality Nurse also confirmed the continued review of elopement interventions and audits through the QAPI process. She stated that elopement had been added to the list of topics and information to review. (11) All corrective actions were completed on 6/8/2023 and the immediacy of the IJ was removed on 6/9/23.

Based record review and staff interview, the facility failed to maintain resident (R#1) medical record in accordance with accepted professional standards and practice by ensuring a LPN did not falsify documentation pertaining to R#1's blood sugar, medication administration and safety checks from a sample of eight residents. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: schizophrenia, major depressive disorder, acute encephalopathy, hypertension, schizoaffective disorder, auditory and visual hallucinations, diabetes mellitus type II, Bipolar, communication impairment, neurological muscle weakness, risk of elopement from cognitively impaired subject, and wandering. The resident had a care plan since 11/22/21 for elopement behaviors managed to prevent harm, wanders at night and history of opening windows or checking to see if doors are locked with the following interventions: perform frequent location checks if exit seeking behavior and utilize Wander Alert device. There was also a physician's order since 11/5/21 to monitor resident for exit seeking behaviors six times per day following 9/29/21 incident (eloped from facility). Review of the Safety Checks TAR revealed LPN AA documented on 5/16/23 she monitored the resident at 1:41 p.m. and at 5:44 p.m. although the resident had already eloped from the facility. Review of the 5/16/23 Crisp County Sheriff's Office Incident Report revealed the Deputy spoke to staff that identified herself as the [NAME] President of the facility and told the deputy that she had contacted the employee (LPN AA) that was responsible for checking the resident's blood sugar. She stated she found out her employee had lied about checking R#1's blood sugar at 4:30 p.m. She reported the last time anyone at the facility accounted for R#1 was at 12:30 p.m. Review of the active physician's orders revealed the following orders: - Blood glucose monitoring four times a day before meals and bedtime with sliding scale insulin - Novolog 70/30 insulin 26 units twice a day - glimepiride (oral diabetes medicine) 4 milligrams (mg) twice a day with meals Review of the May 2023 Medication Administration Record (MAR) revealed LPN AA falsified documentation by documenting she administered glimepiride 4mg on 5/16/23 at 5:44 p.m., and documented she checked the resident's blood glucose at 1:41 p.m. and at 5:44 p.m. although the resident was not in the facility at those times. During an interview with LPN AA on 5/30/23 at 1:35 p.m. she stated she checked the resident's blood sugar on 5/16/23 around 11:00 a.m. or 11:30 a.m. and last saw the resident between 11:30 a.m. or 12:00 p.m. walking around Station 2 where his room was. She stated she made up the resident's blood sugars and falsified the documentation. At 4:30 p.m. she to look for the resident to check his blood sugar but she did not see him in his room, and she didn't even think to go and look for him, she just continued to go and check other resident's blood sugars. During an interview with the Administrator on 5/18/23 at 11:15 a.m., she stated that LPN AA later confessed to her that she had actually falsified the record and had not given R#1 his medication. She the nurse resigned before she could terminate her but she was reporting the nurse to the board of nursing.

Based on observations, staff interviews, and review of the facility policy titled Crisp Regional Health Services Medication the facility failed to ensure that two of four medication carts were locked and secured when not in use. Findings include: Review of the policy titled, Crisp Regional Health Services Medication, dated 6/11/2021, revealed under number 24., the medication cart should always be locked unless in use by the Unit Nurse. 1. Observation on 10/19/2021 from 12:41 p.m. until 12:48 p.m., RN NN entered room [ROOM NUMBER] to assist a resident. While the RN NN was in the room two surveyors observed medication cart #3 to be open. The light on the cart was orange and the drawers on the cart were able to be opened including the narcotics drawer. RN NN was observed to exit room [ROOM NUMBER] and assist a resident in room [ROOM NUMBER]. RN NN was observed to exit room [ROOM NUMBER] and walk off the hall. During this time the med cart was still observed by two surveyors to be unlocked. RN NN returned to medication cart #3 and locked the cart. Interview on 10/19/2021 at 12:51 p.m. RN NN stated she did not leave the cart unlocked and that she always locks the med cart when she walks off. 2. Observation on 10/21/21 at 8:50 a.m. surveyor walked up to Med Cart #2 and LPN AA was in the process of preparing medication for R#17. Surveyor informed LPN AA that the surveyor would observe full preparation of the next resident as she prepared medications for that resident. At 8:52 a.m. LPN AA took medications into room of R#17 and failed to secure the top medication drawer. The top drawer contained a two-week supply of medications for residents in rooms 101 A through 106 B and contents of the drawer could have been accessible to anyone passing by the cart if surveyor had not been present. The medication drawer was open for three minutes until LPN AA came back to the cart at 8:55 a.m. When LPN AA was shown by surveyor the top drawer of medication cart had remained open while she had been in R#17's room she replied, Sorry, I thought I pushed it in. LPN AA proceeded to close the top drawer to secure medication cart. Interview on 10/22/2021 at 10:59 a.m. with Director of Nursing (DON), the DON stated the facility just received the new medication carts and the facility staff, including agency staff, are provided with education on the medication cart and medication administration. She stated staff are constantly educated on locking the medication cart when leaving the medication cart unattended. She stated her expectation would be for the nursing staff to keep the medication carts locked at all times when not in use.

Based on observation, interview, record review, review of facility policy titled, Medication it was determined the facility's medication error rate was greater than five percent. A nurse was observed to crush/open three medications that according to Cleveland Clinic reference documentation should not be crushed and/or opened. There were 31 opportunities observed during medication administration with three errors noted which resulted in the facility's medication error rate of 9.6%. This medication error affected one of seven residents observed for medication administration. The findings include: Review of facility policy, Medication with review date 6/11/21, revealed the facility will provide pharmaceutical services including procedures that assure accurate administering of medications to meet the needs of each resident. The nurse should review the medication for any special instructions. If the nurse in unfamiliar with a medication, the nurse should: Look up the medication search within the facility's electronic medical record and/or call the pharmacist/physician for clarification. Observation on 10/21/21 at 8:50 a.m. surveyor walked up to Medication (Med) Cart #2 and LPN AA was in the process of preparing medication for R#17. Immediately after administering medications to R #17 LPN AA proceeded to obtain medications from the medication cart for R#3. The medications included: acidophilus one tablet, cranberry 450 milligrams (mg) one tablet, [MEDICATION(S)] sodium100 mg one capsule, vitamin D 25 micrograms (mcg) one tablet, [MEDICATION(S)] 0.5 mg one tablet, [MEDICATION(S)] 75 mg one tablet, [MEDICATION(S)] 125 mg one tablet, [MEDICATION(S)] 20 mg one tablet, [MEDICATION(S)] 20 mg one capsule, losartan 50 mg one tablet, [MEDICATION(S)] 5 mg one tablet and [MEDICATION(S)] 20 mg one capsule. LPN AA proceeded to place the tablets and [MEDICATION(S)] sodium 100 mg capsule in plastic sheet and stated she was going to crush the resident's medications and put the medications in milk due to the resident liking milk. LPN AA said she was an agency nurse and it had been a while since she had worked on the medication cart, and at some point, the resident was having some problems with swallowing. The surveyor asked LPN AA if R#3 was having problems swallowing now. LPN AA replied she did not know and began crushing the medications and then proceeded to open the [MEDICATION(S)] 20 mg capsule and [MEDICATION(S)] 20 mg capsule. Just prior to opening the capsules surveyor asked the LPN was it appropriate to open the capsules, and LPN replied, I don't know. She proceeded to open the capsules and placed the contents in with the crushed medications. The contents of the crushed medications and opened capsules were put in small glass of milk and the resident proceeded to drink the contents in the glass. The medications were administered to R#3 at 9:03 a.m. Review of the website https://my.clevelandclinic.org > health > drugs revealed the following: Medication presented in capsule form is designed to be swallowed. Some capsules may be harmful if crushed or opened. Do not crush, chew, or break open a [MEDICATION(S)] capsule or tablet. Take [MEDICATION(S)] capsules exactly as directed and swallow the delayed-released capsule whole and do not crush, chew, break, or the capsules. [MEDICATION(S)] swallow the capsule whole and do not split, crush, or chew the capsule. On 10/21/21 at 9:25 a.m. the Administrator and Director of Nursing (DON) were informed of the med error rate of 9.6 %. The DON stated the [MEDICATION(S)] capsule and [MEDICATION(S)] capsule should not have been opened and that [MEDICATION(S)] sodium is available in liquid form if the resident needs it. During an interview with the DON on 10/22/21 at 11:15 a.m., she stated when agency nurses come to facility they should be prepared to come to work as a nurse. She stated nursing staff will ask the agency nurses if they want orientation and if they do, the facility provided as much orientation as the agency nurses need. She said all nurses should know to check to see if capsules may be opened prior to administering to residents.

Based on observation, staff interview and review of the facility policy titled, Activities of Daily Living the facility failed to ensure that Activities of Daily Living (ADLs) assistance was provided for one resident (R#34) of 23 sampled residents that was dependent on staff for ADL care. The findings include: Review of the facility policy Activities of Daily Living (ADLs) dated 6/11/21 revealed: The facility environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. Residents whom [sic] are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Residents are provided with appropriate care and services including: a. hygiene. Review of the Admission Minimum Data Set (MDS) for R#34 dated 9/10/21 indicated admission into the facility on [DATE] from an acute hospital. R#34 had a Brief Interview Mental Status (BIMS) score of 15 which indicated intact cognition. No behaviors were noted. R#34 required extensive assistance of two persons for bed mobility, transfers, mobility off the unit and toilet use. The resident required set up only for bathing, supervision for personal hygiene and eating. R#34 required limited assistance of two persons for walking in room or corridor and on the unit. The resident had no impairment in range of motion in upper or lower extremities, required a walker or wheelchair for mobility. Interview with R#34 on 10/19/21 at 10:48 a.m. revealed that she received bed baths on Mondays, Wednesdays, and Fridays. The resident stated that her hair had not been washed since her admission into the facility on [DATE]. Interview with medication nurse Licensed Practical Nurse (LPN) DD on 10/21/21 at 1:00 p.m. revealed that residents are to get their hair washed when they get their baths. Interview and observation with the MDS Nurse and R#34 in the resident's room on 10/21/21 at 2:00 p.m. revealed that the resident's hair had not been shampooed since her admission into the facility. R#34 confirmed that her hair had not been shampooed. R#34 stated that when she requested a shampoo, she was notified by an (unidentified) Certified Nursing Assistant (CNA) that she would have to purchase hair care products for her type of hair (African American). R#34 was informed by the MDS Nurse that she was not required to purchase products and that the facility provided shampoo.

Based on observation, staff interviews, and review of the facility policy titled, Incontinent Care, the facility failed to provide incontinent care prior to pressure ulcer wound treatment for two residents (R#2, R#3) of three sampled residents. Findings include: Review of the facility policy titled, Incontinent Care, effective date June 1, 2011, Policy Statement: When urine or stool comes in contact with the skin, they should be removed as soon as possible by gentle cleansing with a washcloth, soap and water or peri-wash. Incontinent care will be given as needed: to provide care in a manner that preserves resident dignity. To maintain adequate skin care. To control odor and prevent skin damage. 1. Review of the medical record revealed R#2 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R#2 had a Brief Interview of Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of the MDS assessment indicated total dependence with two staff physical assistance needed for toileting. During an observation on 5/19/2021 at 1:13 p.m. the Registered Nurse (RN) BB wound care nurse during wound care nurse explained to the resident that he was going to change her dressing. When he unfastened her incontinent brief, the resident was soiled with feces. He took the brief with feces and rolled toward the front of the resident without removing and tucked the brief between R#2's legs. He pressed the call light for the resident to get assistance. However, the CNA did not return, and the call light was turned off. The resident repeatedly stated that she needed to be change. An interview on 5/19/2021 at 1:26 p.m. with R#2 who reported that that it's been over 30 minutes since she had pooped on herself. R#2 constantly asked for her call light and RN BB wound care nurse told her that he would put the call light in place after he finished with her roommate and will fix her up. An interview on 5/19/2021 at 2:31 p.m. with Certified Nurse Aide (CNA) AA revealed that she had changed the resident at 9:00 a.m. and 12:15 p.m. CNA AA reported that she was getting ready to change the resident again, but RN BB wound care nurse told her to come back after he was finished. She stated that she had tried two or three times to change the resident. An interview on 5/20/2021 at 1:43 p.m. RN BB treatment nurse revealed that the resident was soiled with feces. When asked as to why he did not allow CNA AA to change the resident or why he did not perform incontinent care before doing wound care, RN BB stated because the surveyor was standing there waiting to see wound care and that he was trying to do the wound care as quickly as he could. 2. Review of the medical record revealed R#3 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 5, indicating severe impairment. Further review of the MDS assessment indicated dependence with two-person physical assistance by staff for toileting. During an observation on 5/19/2021 at 1:45 p.m. of RN BB wound care nurse, who was preparing to change the sacrum wound dressing. R#3's incontinent brief was soiled with a bowel movement. RN BB wound care nurse rolled resident's incontinent brief and tucked it toward the front of her thighs. The incontinent brief with feces remained on the resident after wound care. An interview on 5/20/2021 at 1:43 p.m. with RN BB wound care nurse who revealed that the answer he gave for R#2 is the same for R#3 regarding why incontinent care was not provided prior to wound care. RN BB wound care nurse did not provide additional information for R#3's incontinent care. An interview on 5/20/2021 at 2:27 p.m. with the Administrator revealed that nurses should follow the facility policies and incontinent care for the residents should have been provided before the wound treatment.

Based on record review and staff interviews, the facility failed to follow the pressure ulcer care plan intervention to provide skin care after each incontinent episode and as needed for two residents (R#2, R#3) of three sampled residents. Findings include: 1.Review of the medical record revealed R#2 was admitted to the facility with the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 3/29/2021 revealed an unstageable pressure ulcer to the sacrum. One of the resident's interventions was for skin care after each incontinent episode and as needed. During an observation on 5/19/2021 at 1:13 p.m. Registered Nurse (RN) BB wound care nurse was observed changing a sacrum dressing without properly providing incontinent care to remove feces from the resident. He moistened a 4 x 4 gauze with normal saline and wiped the skin where the adhesive dressing was applied. R#2 remained in a soiled incontinent brief after her dressing change and during her roommate's dressing change which was directly after R#2. An interview on 5/19/2021 at 2:31 p.m. with Certified Nursing Aide (CNA) AA revealed that she had changed the resident at 9:00 a.m. and 12:15 p.m. CNA AA continued to state that she was getting ready to change the resident, but RN BB wound care nurse told her to come back after he was finished. She stated that she had tried two or three times to change R#2. An interview on 5/20/2021 at 1:43 p.m. with RN BB wound care nurse who acknowledged that R#2 was soiled with feces when CNA AA attempted to change the resident three times prior to wound care. It was further reported that he did not allow CNA AA to provide incontinent care because the surveyor was standing there wanting to see wound care and he was trying to do the wound care as quickly as he could. An interview on 5/20/2021 at 2:27 p.m. with the Administrator revealed nurses should follow the facility policies. The Administrator also reported that incontinent care for the residents should have been provided before the wound treatment. 2. Review of the medical record revealed R#3 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 4/6/2021 revealed that R#3 had an unstageable pressure ulcer to the coccyx and an unstageable pressure ulcer to the left hip. One of the resident's interventions was for skin care after each incontinent episode and as needed. During a sacral wound treatment observation on 5/19/2021 at 1:45 p.m. RN BB wound care nurse opened the adult incontinent brief, and the resident had a bowel movement. RN BB wound care nurse moistened a 4x4 gauze with normal saline and wiped the skin around the wound. He then applied an adhesive dressing after he completed the wound care order. The adult incontinent brief remained on the resident with the feces and drainage from her wound. An interview on 5/20/2021 at 1:45 p.m. with RN BB wound care nurse revealed that he did not provide incontinent care to the resident before doing wound care. He stated that the surveyor already knew the answer and that his answer was the same as he answered for resident #2. RN BB did not provide any additional information. An interview on 5/20/21 at 2:27 p.m. with the Administrator revealed nurses should follow the facility policies and incontinent care for the residents should have been provided before the wound treatment. Cross refer F690

Based on observation, record review, staff interviews, and review of policy titled, Skin & Wound Care Management Program the facility failed to accurately stage and thoroughly assess pressure ulcers for one resident (R#1) of three sampled residents and the facility failed to ensure that pressure ulcer treatment was without the risk of feces contamination for two residents (R#2, R#3) of three sampled residents. Findings include: Review of the policy titled Skin & Wound Care Management Program (Issued date 11-22-17) revealed 2. A resident having ulcers will receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from develop if consistent with overall clinical condition and individualized goals of care. 1. During a closed record review it was revealed that R #1 was readmitted to the facility on [DATE] after a lengthy hospitalization with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed R#1 was identified as being at risk of pressure ulcers, but no pressure ulcers were identified. R#1 had a hospital stay from 12/17/2020 and returned to the nursing facility on 1/6/2021. Review of the Integumentary (weekly skin assessment) dated 1/7/2021 revealed no evidence that a pressure ulcer to the sacral was present on R#1 during readmission to the facility. A nursing narrative note dated 1/7/2021 revealed that a licensed nurse had assessed the resident's skin upon returning from the hospital on 1/6/2021. There was no evidence of the 1/6/2021 skin assessment or nursing note to reflect the finding of a pressure ulcer on the sacrum. Review of the Integumentary (weekly wound assessment) dated 1/8/2021 revealed resident had opened areas of excoriation on his groin, buttocks, lower back, and upper back of his legs that were present on admission. There was no evidence that the resident had a pressure ulcer to the sacrum. The weekly wound assessment dated [DATE] revealed that resident had an unstageable coccyx pressure ulcer that slough and/or eschar. The measurements obtained were 6.5 cm x 5.0 cm x 4.0 cm. There was a wound treatment order for Dakin's solution and foam dressing. Review of the Nursing Narrative Note dated 1/19/2021 revealed that a family member contacted the facility and wanted the resident to see a wound specialist. The treatment nurse explained to the family member that he did not see the DTI (deep tissue injury) due to the raw area to the buttocks. He documented that the wound was not seen until later when it opened up with slough to the wound bed. Review of the wound care specialist report dated 1/25/2021 revealed resident was at the clinic for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The modifying factors for the patient's wounds ulcer worsening was due to lack of treatment. The patient had pressure ulcers to his bilateral buttocks as well as a [MEDICATION(S)] infection. There were five identified open areas with four having an etiology of fungal; 1. The right groin (etiology of fungal) wound measurements were 20 cm x 18 cm 0.1; 2. The left groin(etiology of fungal) wound 22 cm x 7 cm x 7 cm; 3. The right gluteus (etiology of fungal) wound measurements were 36 x16 x 0.1; 4. The left gluteus (etiology of fungal) wound measurements were 48 x 14 x 0.1; 5. The sacrum (etiology was a pressure injury) wound measurements were 8 cm x 5.5 cm x 4 cm with 67-100% amount of necrotic tissues within the wound bed including eschar and adherent slough. The sacrum had an excisional skin/subcutaneous tissue debridement with the post sacrum wound debridement measurements were 8.0 cm x 5.5 cm x 4.0 cm. The sacrum wound was staged as a stage IV. The wound care specialist listed all the wounds as being acquired on 12/31/2020. An interview on 5/20/2021 at 1:48 p.m. with RN BB wound care nurse revealed that resident returned from the hospital on 1/6/2021. The resident was having diarrhea and was missing skin with bleeding tissue. RN BB wound care nurse reported that if the resident had a DTI, he could not identify the DTI because of the bleeding tissue. 2. Review of the Progress Note Final Report (Physician clinical note) dated 5/7/2021 revealed R#2 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 5-day assessment dated [DATE] indicated at risk for pressure ulcers and one pressure ulcer present on admission. During an observation on 5/19/2021 at 1:13 p.m. RN BB wound care nurse explained to R#2 that he was going to change her dressing. He sanitized his hands and donned gloves. When he unfastened the incontinent brief, the resident was soiled with feces. RN BB wound care nurse then took a 4 x 4 gauze and moistened the gauze with normal saline and wiped the skin around the wound. He took the brief with feces and rolled toward the front of the resident and tucked the brief. After the completion of wound care for R#2 there was visible fecal material below the edge of the adhesive dressing. An interview on 5/20/21 at 1:43 p.m. RN BB wound care nurse revealed that the resident was admitted with an unstageable sacrum pressure ulcer and a surgical wound to her left hip with staples. He stated that the nurses are responsible for the weekly skin assessment. And that the resident was in the hospital on 5/5/2021. When RN BB wound care nurse was asked to state whether resident was dry, wet, or soiled he said she was soiled with feces. He was also asked why he did not allow Certified Nursing Aide (CNA) AA to provide incontinent care before the wound dressing change on her three attempts. He stated that the surveyor was standing in the room waiting to see wounds care and he was trying to do the wound care as quickly as he could. 3. Review of the Medical record revealed R#3 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS admission assessment dated [DATE] indicated pressure ulcers on admission. An observation on 5/19/21 at 1:45 p.m. of RN BB wound care nurse who opened the incontinent brief for R#3 and it had a bowel movement. RN BB wound care nurse took a 4x4 gauze and moistened the gauze with normal saline and wiped the skin around the wound. He then took the brief and tucked it toward the front of the resident's thighs. The adult brief with the feces and drainage from the wound remain on the resident upon exiting the room.

Based on observation, record review and staff interview, the facility failed to apply a right hand/wrist splint to prevent further contracture for one resident (R) (#63). The sample size was 37 residents. Findings include: Review of the clinical record revealed R#63 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#63 was unable to complete the Brief Interview of Mental Status (BIMS) Assessment and had functional limitations in range of motion (ROM) on both sides of the upper and lower extremities. Review of the quarterly Restorative Nursing Summary dated (MONTH) (YEAR) documented R#63 is on the restorative program for passive ROM and splinting. Review of the Activities of Daily Living (ADL) sheet for (MONTH) (YEAR) revealed to apply splint to right hand-wrist on in a.m. and off in p.m. Observations on 10/30/18 at 2:47 p.m., 10/31/18 at 9:38 a.m. and 3:28 p.m.; and 11/1/18 at 8:19 a.m. and 11:05 a.m. revealed R#63 with no splint applied to a right hand/wrist contracture. The splint was observed in a chair on the other side of the resident's room. Review of the Rehab Certified Nursing Assistant (CNA) Roster for R#63 revealed no documentation related to splint/brace application for 10/26/18 through 10/31/18. Interview with CNA AA on 11/01/18 at 11:17 a.m. revealed that R#63 does not wear the splint to the right hand/wrist. CNA AA stated that the splint had been discontinued. Interview with Occupational Therapist (OT) BB on 11/01/18 at 9:40 a.m. revealed that R#63 is currently on case load and receives physical therapy. She stated that the CNA's should be putting the splint on the resident's right hand/wrist in the morning and removing at night. Further observation and interview with OT BB on 11/01/18 at 12:08 p.m. revealed that R#63 was able to do more with ROM than the previous visit, so he has not had a decline in ROM to right hand-wrist. Observation on 11/01/18 at 1:25 p.m. revealed R#63 wearing the right hand/wrist splint with no difficulties. Review of the undated policy titled Restorative Therapy Program revealed: Policy: The restorative program is an interdisciplinary process. The restorative aide and restorative CNA will be responsible for implementing the restorative program 6-7 days per week and will work under the supervision of the nursing department. Procedure: 1. The therapist and/or nursing staff will evaluate and design a program appropriate for resident/patient's physical condition and disability. 4. All treatments provided by the restorative aide/CNA will be recorded in the clinical record. The supervising licensed nurse will document a quarterly note/ comment in the clinical record. 6. The residents/patient's care plan will be changed appropriately. Reassessment for continued need and resident/ patient's function will be performed with each quarterly RAI, unless otherwise indicated by change in condition or therapist recommendation.

Based on observation, record review, and staff interview, the facility failed to keep a Foley Catheter anchored to one resident's (R) leg (R#40) to prevent tension on the urinary meatus. The sample size was 37 residents. Findings include: Review of R#40's Annual Minimum Data Set, (MDS) assessment dated [DATE] revealed that R#40 had a Brief Interview for Mental Status (BIMS) score of 0 which indicates severe cognitive impairment; an indwelling catheter and Pressure Ulcer of sacral region Stage IV present on admission. Review of the incontinent care plan with risk for Urinary Tract Infections (UTI's) revealed an intervention to observe for signs and symptoms of a UTI. Review of R40's Physician orders [REDACTED]. Observation on 10/29/18 at 2:20 p.m. and 10/30/18 at 8:30 a.m. and 10/31/18 at 1:00 p.m. revealed that the Foley Catheter tubing was not anchored to R#40's leg to help prevent excessive tension on the catheter during positioning, transferring and providing care. Interview with Certified Nursing Assistant (CNA) CC on 10/31/18 at 3:10pm revealed the Foley catheter is supposed to be anchored to resident's thigh. CNA CC stated that he ensures it is anchored when he changes and repositions resident. CNA CC revealed that the catheter was not anchored to resident's thigh when he entered R#40's room to provide peri care and he informed the nurse. An interview was conducted with the DON on 11/01/18 at 1:00 p.m. and she informed that her expectations is that all residents with a Foley Catheter should ensure the tubing is anchored to the resident's leg to prevent tension and discomfort to resident.

Based on observation, record review and staff interview, the facility failed to follow the care plan related to right hand/wrist splint application for one resident (R) (#63). The sample size was 37 residents. Findings include: Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#63 was unable to complete the Brief Interview of Mental Status (BIMS) Assessment and had functional limitations in range of motion (ROM) on both sides of the upper and lower extremities. Review of the care plan last revised 9/12/18 revealed R#63 at risk for decline in ROM and mobility. Interventions included but were not limited to splint/brace application as indicated. Review of the Activities of Daily Living (ADL) sheet for (MONTH) (YEAR) revealed to apply splint to right hand-wrist on in a.m. and off in p.m. Observations on 10/30/18 at 2:47 p.m., 10/31/18 at 9:38 a.m. and 3:28 p.m.; and 11/1/18 at 8:19 a.m. and 11:05 a.m. revealed R#63 with no splint applied to right hand/wrist contracture. The splint was observed in a chair on the other side of the resident's room. Interview with Certified Nursing Assistant (CNA) AA on 11/01/18 at 11:17 a.m. revealed that R#63 does not wear the splint to the right hand/wrist. CNA AA stated that the splint had been discontinued. Interview with Occupational Therapist (OT) BB on 11/01/18 at 9:40 a.m. revealed that R#63 is currently on case load and receives physical therapy. She stated that the CNA's should be putting the splint on the resident's right hand/wrist in the morning and removing at night. Review of the policy titled Care planning - Interdisciplinary Team revised 11/16/16 revealed: 2) The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team which includes, but is not necessarily limited to the following personnel: j. nursing assistants responsible for the resident's care. Cross Refer F688

Based on observations, record review, interviews with facility staff, and review of facility policy's it was determined that administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The facility failed to provide protective oversight of clinical systems to include residents who were identified as fall risk, monitoring of alarm devices for R#3 and R#64, and proper fitting bed mattress for R#1 and R#64 notification to the physician if a resident has a change in condition and failure to conduct an comprehensive internal investigation of incidents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. Findings include: During an interview on [DATE] at 8:45 a.m the Administrator acknowledged the facility failed to thoroughly investigate both resident's (R#3 and R#64) incidences according to the facility policy; also, the facility failed to develop appropriate interventions regarding the resident's altered mental status; use of the specialty air mattress; and the non-functioning pressure alarms. The Administrator stated the facility now has policies/procedures and monitoring system in place to ensure there will not be a reoccurrence. Review of an undated facility document titled Alternating Pressure Pad (Air Mattress) revealed the policy and procedure instructed staff to explain the procedure to the resident and family. Inflate the mattress to the desired level and cover with protective pad cover. Assist the resident to comfortable position on air mattress. Report any malfunctions to the maintenance department. Chart on the clinical record, indicating date and time started and discontinued, progress of the resident's condition. Include pertinent observation. The policy lacked instructions for ensuring the air mattress was secured to bed frame to avoid gaps between the mattress and side rails which could result in a potential entrapment. It also did not contain information referring staff to the manufacturers instructions in order to ensure the mattress was placed on the correct setting. Review of the facility's policy procedure titled Conducting a Thorough Investigation with an effective date of [DATE], documents . (4) develop a list of known and possible witnesses to the alleged incident. Interview and obtain signed statements where possible from the staff, residents, and/or visitors or anyone who has or might have knowledge of the incident that is being investigated. Interview staff on other shifts who might have seen or heard anything such as 24 hours prior to the incident. Interview resident in the room or in the vicinity where the alleged incident occurred who might have seen or heard something. Review of the facility's investigation report dated [DATE] revealed R#64 either slipped or fell from the air mattress that was placed on her bed, becoming entrapped between the side rail and air mattress on [DATE] and expired. Review of R#64's fall care plan revised [DATE] revealed interventions included the use of bed pressure alarm and to deflate air mattress slightly, contrary to the manufacturers instructions. The care intervention lacked specific directions on what deflate mattress slightly meant. Review of the facility's incident report dated [DATE] indicated the resident sustained [REDACTED]. The report documents that the pressure alarm on the resident's bed did not sound when the resident fell . A review of another incident report for R#64 dated [DATE] does not address if the resident's pressure alarm was sounding when the resident had a fall Interview with RN EE on [DATE] at 9:05 a.m. on the 200 Hall revealed the nurse had just received training on specialty air mattresses within the past week. Prior to that the facility had not offered any type of training on the mattresses. Interview on [DATE] at 11:20 a.m. with LPN AA revealed that she had never received any training from the facility on the use of the specialty air mattresses and to her knowledge the facility does not have a policy regarding the use of pressure alarms. During an interview on [DATE] at 11:45 a.m. with the DON she stated the Administrator is responsible for ordering the specialty air mattress for the resident. The company has not provided staff training on the specialty air mattress. The DON may give a mini in service to the nurse assigned to resident. But all nursing staff have been told that no one is to touch or change the settings on air mattresses except for the DON and ADON. The DON acknowledged that care plans are not been developed for those residents on specialty mattresses. Before the [DATE] incident, the facility did not have a system in place to ensure the safety of the residents on air mattresses. The DON also stated that she and the ADON were responsible for assessing the residents that used enable bar(s) or side rails for assistance. However, the facility did not have a monitoring system in place to ensure the safety of the residents using these devices or continued use of these devices. Continued interview with the DON revealed the facility did not have a policy and procedure in place for the use of the pressure alarms for residents identified at risk for falls. The DON stated the restorative aides were responsible for checking the residents with pressure alarms daily during the week and on the weekend the assigned CNA was responsible for checking the pressure alarm. The staff were to document their findings on the checklist sheet and submit to the DON. However, the DON only maintained the sheets for 30 days. There was no other system in place to ensure the pressure alarms were continually monitored for proper placement and functioning capabilities. Cross Reference to F323 The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: 1. R#64 no longer resides at the facility. The facility currently has three residents on specialty air mattress and providing close supervision of those residents to ensure their safety. Currently there are no residents that utilize a pressure alarm system. 2. In-services were conducted ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], and was completed on [DATE] by either the DON, ADON or LPN Charge Nurse on the importance of completing a thorough investigation to include: description of incident, factors related to incident, activity on or before incident, was bed in low position, was bed wheels locked, was specialty mattress secured to the bed, if a specialty air mattress was in use , what was the setting on the mattress, was staff present during activity, type of footwear at time of incident, any assist aides being utilized, was there a restraint being used, were side rails or transfer bar in use , was alarm present and functioning, what was the resident's mental status, what were the vital signs, what was the incident outcome, injury site/type, type of aid provided, notification provided to MD, and Responsible Party, Disposition of patient, witness statements, any new interventions. The facility provided copies of the in-service attendance sheets. 3. A review of the facility's in-service attendance sheets revealed The Senior NHA Administrator in-serviced the Administrator, DON, ADON and Social Services Director on investigation of all occurrences on [DATE]. 4. As of [DATE], 99% of the Nursing Staff; 95% of the Housekeeping staff; 100% of the Dietary staff; 100% of the Administrative staff; 100% of the Activity staff; 100% of the Maintenance staff have been in-serviced. The remaining staff will be in-serviced on the policies prior to working their next schedule shift by either the DON, ADON, or LPN Charge Nurse Supervisor. For any PRN staff, new or contracted employees or staff on FMLA or Worker's Comp will be in-serviced prior to their next assigned shift. 5. A review of a facility document titled Checklist for Incident Investigation was developed by the facility administrative staff to ensure all incidents are thoroughly investigated. The check list documents description of incident, factors related to incident, activity on or before incident, was bed in low position, was bed wheels locked, was specialty mattress secured to the bed, if a specialty air mattress was in use , what was the setting on the mattress, was staff present during activity, type of footwear at time of incident, any assist aides being utilized, was there a restraint being used, were side rails or transfer bar in use , was alarm present and functioning, what was the resident's mental status, what were the vital signs, what was the incident outcome, injury site/type, type of aid provided, notification provided to MD, and Responsible Party, Disposition of patient, witness statements, any new interventions. A review of the checklist for R#3's fall on [DATE] revealed the facility was following policy and A(NAME). 6. During orientation, new Licensed Nursing Staff and new C.N.A.s will be in-serviced on the importance of completing a thorough investigation includes but not limited to: description of incident, factors related to incident, activity on or before incident, was bed in low position, was bed wheels locked, was specialty mattress secured to the bed, if a specialty air mattress was in use , what was the setting on the mattress, was staff present during activity, type of footwear at time of incident, any assist aides being utilized, was there a restraint being used, were side rails or transfer bar in use , was alarm present and functioning, what was the resident's mental status, what were the vital signs, what was the incident outcome, injury site/type, type of aid provided, notification provided to MD, and Responsible Party, Disposition of patient, witness statements, any new interventions. Interview on [DATE] at 1:55 p.m. on the 100 Hall nurses station with LPN MM revealed the LPN was recently hired four days ago for the day shift. The employee stated she had attended several in-services this week regarding facility policies. A review of the facility's in-service attendance sheets verified the employee had attended several in-services on [DATE]. Interview on [DATE] at 6:35 a.m. at the 100 Hall nurses station with RN YY revealed this nurse was recently employed two weeks ago for the night shift. The employee stated she had attended several in-services on [DATE]. A review of the facility's attendance sheets verified the employee attended several training sessions that day. QA Coordinator will then present the findings of all identified deficient to the QA Committee at the next scheduled QA meeting. 8. An interview was conducted with the Administrator on [DATE] at 8:45 a.m. in her office. The Administrator stated she was aware of the [DATE] incident involving R#64 in which the resident became entrapped between the side rail and air mattress and died ; the nursing staff notified her and the DON shortly after the incident occurred. The Administrator states that when she arrived on the scene the sheriff's department was still investigating the resident's room. The Administrator, DON, and Senior Nursing Home Administrator started interviewing the staff present during the incident. The Administrator confirmed they did not obtain written statements from the staff they interviewed. Instead they use the written statements obtained by the sheriff's office to avoid confusion. The Administrator also stated that she did not take any notes documenting her interview with the staff. The Administrator further stated once the sheriff's department released the resident's room, the administrative team inspected the resident's rooms, to decide as to the contributing factors to the incident. However, the Administrator agreed the administrative team failed to document their findings. Regarding previous incidents, the Administrator was not sure if she remembers the resident's fall that occurred on [DATE]. Also, the Administrator was not aware of the pressure alarm malfunctioning in both falls incidences. The Administrator stated that anytime a resident experience a change in mental status or a fall incident it should be documented in the nurses' notes, an incident report with investigation and root cause analysis completed. All resident's changes in condition and incidents are discussed in morning meeting and then followed up in the Falls Committee meeting and Incident Reduction Program meeting. If a severe injury or a pattern is identified it should be brought to the QA meeting. The Administrator stated that she did not attend the [DATE] Quality Assurance meeting.

Based on closed record review, interviews with facility staff , review of the facilities investigation and policies, it was determined the facility failed to notify the physician of a resident's change in mental status for one resident (Resident #64) from a total of nine sampled residents. On [DATE] at 8:30 p.m. R#64 was observed entrapped between the side rails on the bed and the air mattress resulting in death. The Standard was not met and therefore is cited at immediate jeopardy level. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. The findings include: Closed record review revealed R#64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent 30-day Minimum Data Set ((MDS) dated [DATE] assessed the resident with a Brief Interview Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Closed record review of nurses' notes dated [DATE] documents the nurse received report from the off-going nurse that R#64 was talking to dead family and wanting to join them right now in celebration. The nurses' notes further document the resident was observed in her room alone talking to a dead relative. Interview with LPN AA on [DATE] at 11:20 a.m. she confirmed that she noticed after R#64 awaken from her afternoon nap the resident had a change in her mental status. LPN AA stated the resident dreamt about talking to her dead sister-in-law and having a celebration. LPN AA also stated this was a new behavior and this change in the resident's mental status and it concerned her to a point where she continued to closely monitor the resident until the end of her shift. LPN AA decided to move her medication cart closer to the resident's room for closer observation. LPN AA further stated that she did make the on-coming nurse aware of the resident's change in mental status. However, LPN AA did not report the change in the resident's mental status to her supervisor or to the resident's primary care physician. Review of facility document titled Physician Notification with a revision date of [DATE] documents the medical management of a resident is the responsibility of the medical staff, however the facilities (sic) nursing staff is responsible for notifying the attending physicians of medical changes that a resident is experiencing and the need for medical attention. Review of the facility's investigation of the [DATE] incident revealed a witness statement submitted by LPN AA which documents the resident having episodes of talking to herself about having a celebration with a dead family member. Telephone interview with LPN CC on [DATE] at 8:30 p.m. revealed that she was on duty on [DATE]. LPN CC stated that she was aware the resident had periods of confusion but was not aware of the confusion that occurred on [DATE]. LPN CC also stated the resident had an episode of confusion approximately two weeks (unable to remember the exact date) prior to [DATE]. LPN stated the resident had called her to her room to remove a cat from her room. LPN CC stated that she was finally able to convince the resident there was no cat in her room. The LPN further stated that she did not notify the physician of this change in the resident's mental status but that she would continue to monitor the resident. LPN CC confirmed she documented the incident in the resident's medical records. Interview with the ADON (Assistant Director of Nursing) on [DATE] at 10:03 a.m. the nurses are responsible for assessing residents if there is a change in their physical or mental conditions. If there is a change in a resident condition the nurse should notify the nursing supervisor and notify the resident's primary care physician. The nurse should document all of this in the resident's chart. The ADON was made aware of the two episodes in which the resident exhibited a change in mental status; the ADON stated she was unaware of these two episodes. But the nurses should have notified the primary care physician of these incidents.Telephone interview with R#64's primary care physician (PCP) on [DATE] at 11:45 a.m. revealed the PCP was unaware of the resident's periods of confusion. The PCP stated these episodes could have been signs that the resident had a urinary tract or respiratory infection. The PCP further stated if he had been aware of the situations he could have ordered tests to rule out an infection process. In a telephone interview with the facility's Medical Director on [DATE] at 2:20 p.m. the Medical Director was not familiar with R #64's [DIAGNOSES REDACTED]. The two incidents were explained to the Medical Director and he stated the nursing staff should have notified the resident's physician as it was possible the resident was in the process of developing an infection. The facility failed to notify R#64's primary care physician of changes in the resident's mental status prior to the resident's fall incident on [DATE] that resulted in the resident's death. Cross Reference to F323 The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: 1. Record review revealed that Resident (R) #64 was no longer resides at the facility. In-services of all staff were conducted on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], and was completed on [DATE]. The education included training on the following facility policies: Physician Notification, Change in Resident's Condition/Status, Guidelines for Support surfaces in the Prevention of Pressure ulcers; Use of the Care Plan, Incident Policy, Incident Reduction Program, Pressure Alarm Monitoring, Pressure Alarm Checklist, Pre-Assessment for Use of Side Rails or transfer bars, Consent Form for Use of Side Rail, Maintenance rounds, Abuse Policy, and Thorough Investigation of Incidents/Accidents Checklist for Incident Investigation, Use of the Bed Bolster with Checklist list . Educational in-service training was provided by the Administrator, Regional Nursing Home Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Nursing Supervisors. The facility provided copies the training materials on [DATE]. As of [DATE], 99% of the Nursing Staff; 95% of the Housekeeping staff; 100% of the Dietary staff; 100% of the Administrative staff; 100% of the Activity staff; 100% of the Maintenance staff have been in-serviced. The remaining staff will be in-serviced on the policies prior to working their next schedule shift by either the DON, ADON, or LPN Charge Nurse Supervisor. For any PRN staff, new or contracted employees or staff on family medical leave or Worker's compensation leave will be in-serviced prior to their next assigned shift. Interview with the DON on [DATE] at 4:30 p.m. revealed that beginning [DATE] either the Administrator, DON, ADON, LPN Charge Nurse Supervisor, QA Coordinator, or the RN Supervisor will review daily the 24-hour report, the nurses' noted and the communication board to identify any resident that had a change of condition or status, fall or incident. An audit tool was developed to ensure the physician is notified. The audit tool will be completed daily. The audit tool will be submitted weekly to the QA Coordinator by either the DON, ADON, or the LPN Charge Nurse Supervisor. The QA Coordinator will be responsible for determining the facility's compliance in this area and determine if there is a need for review of processes or additional training is required. The QA Coordinator will present the audit findings to the QA Committee. Facility Administration is looking at changing the QA meetings from every other month to monthly. The next schedule QA meeting is [DATE]. 2a. Observation of the 100 Hall nursing communication board on [DATE] at 2:00 p.m. staff documented the following residents with changes in condition: R #14 with increased chest congestion and #15 with vomiting after meals. Review of R#14's nurses' notes dated [DATE] at 9:30 a.m. revealed the resident's PCP was notified of the resident's medical symptoms. Review of the R #15's nurses' notes dated [DATE] at 1:30 p.m. revealed the resident's PCP was notified of this change in the resident's condition. Review of the facility's audit tool dated [DATE] was obtained from the DON reflected the facility followed policy. 2b. Observation of the 100 Hall nursing communication board on [DATE] 10:20 a.m., revealed R#13 experienced a change in condition related to swelling in right [MEDICAL CONDITION] stump. Review of R#13's nurses' notes dated [DATE] revealed the resident's primary care physician was notified. A review of the facility's audit tool dated [DATE] revealed R#13's change in condition notification was being monitored for adherence to facility policy. 2c Observation on the 200 Hall nursing communication board on[DATE] at 9:15 a.m., revealed Resident (R) #12 was found on the floor at the bedside. Review of the R#12's incident report and the nurses' notes dated [DATE] revealed the nurse documented notification of the resident's primary care physician. A review of the facility audit tool dated [DATE] revealed R#12's fall was documented and physician notification was being monitored according to the facility's policy. 3a. Interview on [DATE] at 1:55 p.m. on the 100 Hall nurses station with LPN MM revealed the LPN was recently hired four days ago for the day shift. The employee stated she had attended several in-services this week regarding facility policies. A review of the facility's in-service attendance sheets verified the employee had attended several in-services on [DATE]. 3b. Interview on [DATE] at 6:35 a.m. at the 100 Hall nurses station with Registered Nurse (RN) YY revealed this nurse was recently employed two weeks ago for the night shift. The employee stated she had attended several in-services on [DATE]. A review of the facility's attendance sheets verified the employee attended several training sessions that day. Multidisciplinary staff were interviewed. All staff stated they had attended in-services that included the following topics: Physician Notification, Change in Resident's Condition/Status, Guidelines for Support surfaces in the Prevention of Pressure ulcers; Use of the Care Plan, Incident Policy, Pressure Alarm Monitoring, Pressure Alarm Checklist, Pre-Assessment for Use of Side Rails or transfer bars, Maintenance rounds, Abuse Policy, and Thorough Investigation of Incidents/Accidents. Staff were interviewed and given scenarios related to the training provided. Interviews were conducted on [DATE] and [DATE] as follows: on [DATE] CNA NN 100 Hall 7a.m.-3 p.m.; shift at 2:05 p.m.; LPN LL floater between 100 and 200 Halls. 7a.m.-7p.m. shift at 2:40 p.m.; Bookkeeper OO works in accounting ,[DATE]:30 p.m. shift at 3:05 p.m.; Maintenance technicians PP and QQ rotates between day and evening shifts, at 3:30 p.m.; CNA RR 3 p.m.; -11 p.m.; shift on 200 Hall at 3:35 p.m.; RN EE works 7a.m.-7p.m. shift on 200 Hall at 3:38 p.m.; Dietary Cook SS works rotating shifts at 3:50 p.m.; CNA UU works 3 p.m. -11 p.m. shift on 200 Hall at 4:00 p.m.; Housekeeping aide TT works part time on 7a.m.-3p.m. shift at 4:01 p.m. RN FF works 7a.m.-3p.m. and occasionally on the weekend covers both halls at 4:00p.m.; Dietary Manager (DM) works dayshift but stays until kitchen is closed at 5:05 p.m.; CNA VV 3p.m.-11p.m. shifts floats between 100 and 200 Halls at 5:15 p.m.; LPN WW 7a.m.-7p.m. on 200 Hall at 5:45 p.m. Interviews on [DATE]: ADON works all shifts if necessary at 6:10 a.m.; LPN XX rotates shifts and halls at 6:25 a.m. CNA ZZ works 11p-7a shift floats at 6:45 p.m.; LPN KK works 7p.m.-7a.m. shift on 200 Hall at 6:55 p.m.; CNA AAA works 11p.m.-7a.m. shift on 200 Hall at 7:05 a.m., CNA BBB works ,[DATE] shift on the 200 Hall at 7:10 a.m.; CNA CCC works 7a.m.-3 p.m. shift on 200 Hall at 8:42 a.m.; Housekeeping aide DDD works 7a.m.-3 p.m. shift at 9:25 a.m.; CNA EEE works 7a.m.-3 p.m. shift on 100 Hall at 12:40 p.m.; Housekeeping aides FFF and HHH works the day shift and Laundry aide GGG)works the day shift at 12:50 p.m.; Activities CNA III works 7a.m.-3 p.m. shift at 1:05 p.m.; Social Services Director at 1:15 p.m.; LPN Supervisor JJJ at 1:37 p.m.; LPN KKK works the 7a.m.-7p.m. on the 200 Hall at 1:58 p.m.; CNA works 7a.m.-3 p.m. shift on the 100 Hall at 2:15 p.m.; CNA LLL works the 3a.m.-11 p.m. shift as a floater at 3:15 p.m.; and Maintenance Director at 4:15 p.m. Record review of the in-service sign in sheets verified that the staff interviewed had attended the required in-service training. Interview with the DON on [DATE] at 5:15 p.m. revealed the one employee was on vacation and due to return to work next week; and another employee was on FMLA. The DON stated both employees would be scheduled for training prior to starting their assigned shift. The DON also stated that new employees (for all staff) orientation would include the new and revised policies identified in the AoC.

Based on closed record review, interviews with facility staff, review of facility job description, facility policy, and review of Georgia Practical Nurses Practice Act, it was determined the facility failed to thoroughly assess, document and notify the primary care physician of a change in mental status, a current standard of nursing practice for one Resident ( R) #64 from a total of nine sampled residents . On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. Findings include: A review of the Georgia Practical Nurses Practice Act with a copyright date of 2013 documents the following: The practice of licensed practical nursing (LPN) means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: (A) Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations . A review of a facility's document (undated) title LPN Charge Nurse job description documents in Position Summary The Licensed Practical Nurse is responsible utilizing the nursing process in assessing, planning, implementing, and evaluating patient care. The job description further documents under essential job responsibilities . The LPN provides assigned patients with quality care services consistent with the standards of established by the Nursing Services and Crisp Regional Health Services. A review of the facility document titled Change in Resident's Condition or Status with a revision date of [DATE] documents, Prior to notifying the Physician or healthcare provider the nurse will make a detailed observation and gather relevant and pertinent information for the provider including information that prompted the by the Situation Background Assessment Recommendation (SBAR). Closed record review revealed R#64 was admitted in to the facility with [DIAGNOSES REDACTED]. Review of the nurses' notes dated [DATE] with late entry for [DATE] revealed a note was written by LPN BB. LPN BB documents receiving report from the off-going nurse that the resident was having conversations about death and talking dead family member. LPN BB documents the shift report was given in front of the resident's door to facilitate close observations due to the concerns of the off going nurse concerning R#64 having altered mental status changes. LPN BB further documents that she observed the resident watching TV and proceeded to passing medications. Interview on [DATE] at 11:20 a.m. with LPN AA revealed LPN AA had observed a change in R#64's cognition status on [DATE] during the day shift tour. LPN AA stated that she never heard the resident talk about death and dead people before nor had she ever observed the resident talking to herself. LPN AA stated this was a definite change in the resident's mental status and felt she required closer observation but did not notify the resident's primary care physician. LPN AA also admitted that she failed to document the incident and her concerns in the resident's nurses' notes. Interview with LPN BB on [DATE] at 4:30 p.m. revealed this LPN received report from the off-going nurse on [DATE]. LPN BB confirmed that LPN AA verbalized concerns about R#64's altered mental status. LPN BB stated the resident had periods of altered mental status in the past but not to the extent that was reported to her. LPN BB also stated the resident's past episodes of altered mental status was being monitored but was not reported to the physician. LPN BB further stated that she received verbal report at 7:15 p.m. but did not enter the resident's room to physically assess the resident's mental status. LPN BB stated that the resident appeared to be alright and she did not observed resident again until 8:30 p.m. when she entered the room to administer the resident's medications. At that time, she found the resident entrapped between the side rail and air mattress. The LPN admitted that she failed to give instructions to the assigned Certified Nursing Assistant (CNA) to monitor R #64 closely due to altered mental status changes. Telephone interview with LPN CC on [DATE] at 8:29 p.m. revealed prior to [DATE] the LPN had an occasion to interact with R#64 regarding a cat in the resident's room. LPN CC stated the resident had approached her about a removing a cat from her room. LPN CC also stated this was a change from the resident's normal mental status but planned to continue to monitor the resident. LPN CC admitted the resident's primary care physician was not made aware of this change in the resident's mental status and that she failed to document the incident in the nurses' notes. Interview with the LPN Nursing Supervisor on [DATE] at 2:10 p.m.revealed the nurses have been trained that if a resident experience a change in condition either physical or mental, they must assess the resident; then notify the supervisor who will also assess the resident and then either the LPN or the Supervisor will notify the resident's primary care physician. All of this must be documented in the resident's chart. The LPN Nursing Supervisor was not told about the two incidents where R#64 had altered mental status changes, LPN Nursing Supervisor stated the she was unaware of the incidents. Also, the nurses involved did not follow the facility's policy regarding change in resident's condition. In a telephone interview with the facility's Medical Director on [DATE] at 2:20 p.m. the Medical Director was not familiar with R #64's [DIAGNOSES REDACTED]. The two incidents were explained to the Medical Director and he stated the nursing staff should have notified the resident's physician as it was possible the resident was in the process of developing an infection. The facility's licensed staff failed to thoroughly assess and document R#64 change in mental status and notify the physician in accordance to the facility policies and the Georgia Practical Nurse Act. S/S J Cross Reference to F157 and F323 The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: 1. Record review revealed R#64 no longer resides in the facility. 2. On [DATE] The DON reviewed all residents in the facility to identify if any resident experienced any significant change in physical/emotional/mental condition or sustained any falls with or without injury. 3. In-services were conducted ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], and was completed on [DATE]. The education included training on the following facility policies: Physician Notification, Change in Resident's Condition/Status, Guidelines for Support surfaces in the Prevention of Pressure ulcers; Use of the Care Plan, Incident Policy, Incident Reduction Program, Pressure Alarm Monitoring, Pressure Alarm Checklist, Pre-Assessment for Use of Side Rails or transfer bars, Consent Form for Use of Side Rail, Maintenance rounds, Abuse Policy, and Thorough Investigation of Incidents/Accidents Checklist for Incident Investigation, Use of the Bed Bolster with Checklist list . Educational in-service training was provided by the Administrator, Regional Nursing Home Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Nursing Supervisors for all shifts. The facility provided copies the training materials and attendance sheets on [DATE]. As of [DATE], 99% of the Nursing Staff; 95% of the Housekeeping staff; 100% of the Dietary staff; 100% of the Administrative staff; 100% of the Activity staff; 100% of the Maintenance staff have been in-serviced. The remaining staff will be in-serviced on the policies prior to working their next schedule shift by either the DON, ADON, or LPN Charge Nurse Supervisor. For any PRN staff, new or contracted employees or staff on FMLA or Worker's Comp will be in-serviced prior to their next assigned shift. 4. Interview with the DON on [DATE] at 4:30 p.m. revealed that beginning [DATE] either the Administrator, DON, ADON, LPN Charge Nurse Supervisor, QA Coordinator, or the RN Supervisor will review daily the 24-hour report, the nurses' noted and the communication board to identify any resident that had a change of condition or status, fall or incident. An audit tool was developed to ensure compliance with physical assessments for resident experience a change in condition. The audit tool will be completed daily. The audit tool will be submitted weekly to the QA Coordinator by either the DON, ADON, or the LPN Charge Nurse Supervisor. The QA Coordinator will be responsible for determining the facility's compliance in this area and determine if there is a need for review of processes or additional training is required. The QA Coordinator will present the audit findings to the QA Committee. 5a. Record review for R#14 revealed nurses' notes dated [DATE] at 9:30 a.m., indicated the nurse documented a physical assessment for the resident for vomiting related to the resident's change in condition that was identified on the communication board. 5b. Record review for R #15 revealed nurses' notes dated [DATE] at 1:30 p.m. the nurse documented a physical assessment for the resident's chest congestion related to the resident's change of condition that was identified on the communication board. Review of the facility's audit tool dated [DATE] was obtained from the DON reflected the facility was following policy. 6. Review of R#13's nurses' notes dated [DATE] reveals the nurse documented a physical assessment of the swelling in the right [MEDICAL CONDITION] stump since it was identified as a change in condition on the communication board. A review of the facility's audit tool dated [DATE] revealed R#13's change in condition notification was being monitored for adherence to facility policy and AoC. 7. Review of R#12's nurses' notes dated [DATE] revealed the nurse documented a complete head to toe physical assessment after the resident sustained [REDACTED]. A review of the facility audit tool dated [DATE] revealed R#12's fall was documented and assessment was being monitored for adherence to the facility's policy and AoC. 8. Please refer to in-service interviews. Record review of the in-service sign in sheets verified that the staff interviewed had attended the required in-service training.

Based on record review, observation, and interview, it was determined the facility failed to provide care in accordance with the care plan for one Resident ( R) #64 from a total of nine sampled residents. Resident (R) #64 was admitted to the facility on [DATE]. Review of the facility document titled Fall Risk assessment dated [DATE] revealed R#64 was at a high risk for falls. Review of the resident's care plan dated [DATE], revealed the resident was at risk for falls related to recent right hip and right femur fractures and urinary tract infections [MEDICAL CONDITION]. Interventions included observe the resident for any changes that may warrant increased assistance and notify the physician as appropriate. On [DATE], R#64 experienced a change in mental status and the facility nursing staff failed to notify the physician. Resident #64's fall interventions included the use of a pressure alarm, low bed, and deflate air mattress slightly. The facility failed to provide the fall interventions as planned. Review of the facility's investigation of a fall incident that occurred on [DATE] failed to reveal the use of pressure alarm, bed in low position, and air mattress settings. The resident became entrapped between the air mattress and the bed siderail and expired. This standard is cited at a harm level. The sample size was 27 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. Findings include: Review of R#64's care plan dated [DATE] revealed the resident was identified at risk for falls and UTIs. The interventions included observe the resident for any changes that may warrant increased assistance and notify the physician as appropriate. Review of the plan of care last updated ,[DATE] included the following interventions: pressure alarm to the bed, low bed and deflate air mattress slightly. Right leg brace on at all times; right and left enabler bars/side rails and monitor for effectiveness or need for continued use of transfer bars; check positioning and assist to reposition as needed; give resident verbal reminders not to ambulate or transfer without assist; total Hoyer lift for transfers; PT and OT as appropriate; observe for changes in the resident's condition that may warrant increased assistance; ensure the bed is in the lowest position; assist resident with locomotion to various activities and other areas of interest, bilateral bed bolsters Review of the facility's investigation initiated on [DATE] by the Administrator lacked documentation regarding the pressure alarm, position of the bed to the floor and the air mattress setting. Review of the Nurse's Note dated [DATE] at 7:30 a.m. revealed, on [DATE] at 8:30 p.m. Licensed Practical Nurse (LPN) BB proceeded to R#64's room to administer medication. LPN BB opened the door to the room and the resident was visualized on the floor with her head in between the side rails and the mattress. Attempted to call LPN AA again via telephone on [DATE] at approximately 3:00 p.m. regarding the use of the pressure alarm was unsuccessful and LPN AA did not return the phone call as requested. Interview with MDS Coordinator EE (identified as the nurse contact during the survey) on [DATE] at 1:20 p.m. revealed she did not know if the pressure alarm sounded at the time of the fall. Interview on [DATE] at 1:58 p.m. with LPN BB revealed, she did not hear the pressure alarm going off when she entered R#64's room upon request from the resident's nurse at the time of the fall. On [DATE] at approximately 2:30 p.m. the Administrator provided the type of pressure alarm that was on R#64's bed at the time of the incident. Observation at that time revealed the pressure alarm operated by batteries. Review of R#64's record lacked evidence that the facility routinely checked the working condition of the pressure alarm. Interview with the Administrator on [DATE] at 2:35 p.m. revealed the Administrator is responsible for conducting investigations of facility accidents. The Administrator stated the staff did not report if the pressure alarm sounded. The Administrator stated the Director of Nursing (DON) had deflated the air mattress slightly but did not know how much. Interview with LPN AA on [DATE] at 11:20 a.m. revealed the LPN noticed a change in R#64's mental status on [DATE] and decided to monitor the resident closely. However, LPN acknowledged that she did not report the change in mental status to the resident's primary care physician. During an interview on [DATE] at 11:45 a.m. with the Director of Nursing (DON ) she stated even though the resident's BIMs scored indicated the resident was cognitively intact she did exhibit periods of slight confusion, but it seemed to occur for short periods of time and then her mental status would return to normal. The DON didn't feel it was necessary to report these episodes to the primary care physician. Cross Reference to F323 The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: 1. R# 64 who triggered the Immediate Jeopardy no longer resides in the facility. A review of the facility audit tool dated [DATE] revealed the DON did not identify any residents that experienced any significant change in physical/emotional/mental condition, confusion or sustained any falls or injuries. The DON reviewed residents with Pressure Alarms on [DATE] and only one resident (R#3) was identified to have a pressure alarm. On [DATE] the identified resident requested for alarm to be discontinued. A review of the R#3's nurses' notes dated [DATE] the resident requested removal of the pressure alarms. The nurses' notes document it was explained to the resident why he had the pressure alarm to prevent re-occurring falls. The resident's responsible party was notified and gave approval for removal of the pressure alarm devices. As of [DATE] no pressure alarms are being utilized in the facility. A review of the facility's audit tool dated [DATE], revealed the facility did not have any residents utilizing any type of pressure alarm devices. 2a. Beginning on [DATE] the MDS Coordinator added specialty air mattresses to the care plans for three residents (R #1, #4, and #42). This documentation included the type and setting for the specialty air mattresses. Record review revealed the facility had three residents currently on specialty air mattresses. 2b. Review of the care plan with a revision date of [DATE] for R#1 revealed the care plan contained the type of specialty air mattress with a comfort level setting of three alternating. The care plan also included an intervention for the staff not to change the air mattress setting without approval from the DON or ADON. Observation on [DATE] at 10:00 a.m. of R#1 lying in bed on a specialty air mattress with control box setting on comfort level three with alternating pressures. The specialty air mattress was secured to the bed frame and no gaps observed 2c. Review of the care plan with a revision date of [DATE] for R #4 revealed the care plan contained the type of specialty mattress with a setting for 350 pounds (lbs.) with alternating pressure every 25 minutes. Care plan interventions also included directions to the staff not change the mattress setting without approval from the DON/ADON. Observation on [DATE] at 10:10 a.m. on the 200 Hall revealed R#4 lying in bed on a specialty air mattress with a control box setting of 350 lbs. with alternating pressure every 25 minutes. The mattress was secured to the bed frame. An additional observation [DATE] at 2:00 p.m. on the 200 Hall revealed R#4 resting on a specialty air mattress with control settings at 350 lbs. with alternating pressure every 25 mins. Air mattress with straps secured to the bed frame, no gaps observed. Interview with R#4 on [DATE] at 2:00 p.m. revealed the resident understood why the staff was checking his air mattress in order to ensure his safety. R#4 stated he felt good about the frequent checks. 2nd. Review of the care plan with a revision date of [DATE] for R #42 revealed the care plan contained the type of specialty mattress air mattress with a setting of level five and alternating pressure cycle 15 minutes. The care plan also included the directions for the staff not to change the mattress settings without approval from the DON/ADON. Observation on [DATE] at 5:55 p.m. revealed the R#42 in lying in bed on a air mattress with the setting level of five and alternating pressure cycle of 15 minutes. The bed has bilateral side rails with padding. The side rails allow the resident to reposition himself in bed without requesting assistance. There were no gaps observed between the side rails and air mattress. An additional observation on [DATE] at 6:30 a.m. on the 100 Hall revealed the night nurse in R#42's room checking the resident air mattress settings. The resident was on a air mattress with a setting of level five with alternating pressure cycle every 15 minutes. Bilateral side rails in place with padding. Air mattress secured to the bed frame and no gaps observed between the side rails and air mattress. Interview on [DATE] at 6:25 p.m. with LPN XX at the 100 Hall nursing station revealed R#42 had requested the staff not come in his room at night to check his bed. LPN XX stated that she explained to the resident the facility wanted to ensure his safety on the mattress. LPN XX stated that she had notified the ADON of the resident's request and would document it in the nurses' notes. Interview on [DATE] at 6:37 a.m. with R#42 regarding his air mattress he resident was aware of the [DATE] incident that resulted in a resident's death. The resident stated he has never had a problem with his air mattress. R#42 also stated he felt more secure with the frequent checks on his air mattress. A review of the facility's audit tool dated [DATE] revealed the facility was monitoring the residents' care plans for implementation of interventions and revision/update after incident or change in condition occurs according to facility policy. 3. In-services were conducted ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], and was completed on [DATE]. The education included training on the following facility policies: Physician Notification, Change in Resident's Condition/Status, Guidelines for Support surfaces in the Prevention of Pressure ulcers; Use of the Care Plan, Incident Policy, Incident Reduction Program, Pressure Alarm Monitoring, Pressure Alarm Checklist, Pre-Assessment for Use of Side Rails or transfer bars, Consent Form for Use of Side Rail, Maintenance rounds, Abuse Policy, and Thorough Investigation of Incidents/Accidents Checklist for Incident Investigation, Use of the Bed Bolster with Checklist list . Educational in-service training was provided by the Administrator, Regional Nursing Home Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Nursing Supervisors. The facility provided copies the training materials on [DATE]. 4. As of [DATE], 99% of the Nursing Staff; 95% of the Housekeeping staff; 100% of the Dietary staff; 100% of the Administrative staff; 100% of the Activity staff; 100% of the Maintenance staff have been in-serviced. The remaining staff will be in-serviced on the policies prior to working their next schedule shift by either the DON, ADON, or LPN Charge Nurse Supervisor. For any PRN staff, new or contracted employees or staff on MLA or Worker's Comp will be in-serviced prior to their next assigned shift. 5. Please refer to in-service interviews. Record review of the in-service sign in sheets verified that the staff interviewed had attended the required in-service training. 6. Interview with the DON on [DATE] at 4:30 p.m. revealed that beginning [DATE] either the Administrator, DON, ADON, LPN Charge Nurse Supervisor, Quality Assurance (QA) Coordinator, or the RN Supervisor will be responsible for daily review of documentation in the nurses' notes to ensure that the care plan is followed and to ensure the physician is notified of a resident's change in condition or status. The nurses' notes will be audited daily by either the DON, ADON, LPN Charge Nurse Supervisor or RN Supervisor to ensure that the care plan is followed and the physician was notified of a resident's change in condition or status. This will be an on-going process utilizing an audit. The audit tool will be submitted weekly to the QA Coordinator by either the DON, ADON, or the LPN Charge Nurse Supervisor. The QA Coordinator will be responsible for determining the facility's compliance in this area and determine if there is a need for review of processes or additional training is required. The QA Coordinator will present the audit findings to the QA Committee.

Based on observation, interviews , record review, and review of manufacturer's operations manual for speciality air mattresses and the facility policies, it was determined the facility failed to appropriately implement fall interventions for three residents (Residents #1, #3,and #64) identified as fall risk from a total of nine residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. Findings include: 1. Closed record review for Resident (R) #64 revealed the resident was admitted to the facility on [DATE]. The residents [DIAGNOSES REDACTED]. Review of the R#64's Fall Risk assessment dated [DATE], revealed a score of 16 (indicating the resident at risk for falls). Review of the resident's 30-day Minimum Data Set (MDS) assessment dated [DATE], indicated the resident scored 13 on the Brief Interview for Mental Status (indicating the resident was cognitively intact). During the assessment period the resident did not exhibit any signs of depression, disorganized thinking, or behaviors. R#64 required extensive assistance of two persons with bed mobility and transfers; total dependence on staff for activities of daily living (ADLs); range of motion (ROM) impairment of one lower extremity; only able to balance from sitting to standing position with assistance from the staff; and utilized a wheelchair for ambulation. The resident had a Foley catheter and was incontinent of bowels. The resident was admitted with one unstageable ulcer and sustained one fall prior to admission to the facility. Due to the resident's [DIAGNOSES REDACTED]. The facility was unable to provide documentation as to the date R#64 was placed on the air mattress or the setting of the air mattress. On [DATE], the resident sustained [REDACTED]. Review of the incident report revealed the resident's pressure alarm (fall intervention) was not working. The facility's intervention was to deflate the air mattress slightly and add bolsters to the resident's bed. The interventions did not address the resident's non-functioning pressure alarm. A review of the facility's document titled the Resident Incident /report dated [DATE] at 5:30 a.m. documents the alert resident was found on the floor. The report also indicated the air mattress was in place with the siderail's up; alarm in place but did not sound during the incident. The report was incomplete as did not identify what factors were related to the fall: activity order before the incident; or if the resident was wearing foot wear at the time of the fall. The facility was unable to provide a root cause analysis of the fall. Review of the Nurse's Note dated [DATE] at 11:53 a.m. revealed at 5:30 a.m. staff found the resident on the left side of the bed on the floor. The resident stated she had no idea how she ended up on the floor. Fall and safety precautions were: bed lowered, side rails up, and bed alarm in place. Additional review of R#64 fall care plan revealed the care plan was revised on [DATE], to include the following interventions: bilateral bed bolsters and deflate the mattress slightly. The care plan lacked specific directions related to the resident's air mattress and what the term deflate slightly meant. Also, the revised care plan did not address checking the pressure alarm to ensure it was functioning. The facility was unable to provide documentation of what setting the mattress was to be deflated to. Review of the plan of care last updated [DATE] listed the interventions: right leg brace on at all times; right and left enabler bars/side rails and monitor for effectiveness or need for continued use of transfer bars; check positioning and assist to reposition as needed; give resident verbal reminders not to ambulate or transfer without assist; total Hoyer lift for transfers; PT and OT as appropriate; observe for changes in the resident's condition that may warrant increased assistance; ensure the bed is in the lowest position; assist resident with locomotion to various activities and other areas of interest; pressure alarm to bed, bilateral bed bolsters, and deflate mattress slightly. Review of the clinical record lacked evidence of the use of the pressure alarm checks to ensure the pressure alarm was in working condition, and that the mattress was deflated, how much it was deflated, or by whom. The facility was unable to provide training on the use of the pressure alarms, checking for the functionality of the alarms, and on the use of air mattresses. A review of the facility's document titled Fall Prevention Meeting dated [DATE] revealed R#64 was followed in that meeting and the documented interventions included deflate mattress slightly and bilateral bolsters. The issue of the resident's non-functioning alarm was not addressed in the weekly meeting. The resident was not followed after the [DATE] fall prevention meeting. The facility was unable to provide documentation of the resident's tolerance in the change of the air mattress settings. On [DATE], the resident exhibited a change in mental status and attempted to get up unassisted. At approximately 8:30 p.m. on [DATE], the resident was found entrapped between the side rail and air mattress and expired. Review of the facility's investigation of the incident revealed the facility administrative staff failed to conduct a thorough investigation of the incident. Staff interviews revealed the resident's bed pressure alarm was not functioning. Review of the nurses' notes dated [DATE] at 7:30 a.m., revealed LPN ( Licensed Practical Nurse ) BB documents receiving report from off going nurse in front of resident's door. Nurse reports resident has been having conversation about death and speaking about an already deceased sister in law. Nurse states resident told her she was going to her reception with her sister-in-law. Report given in front of resident's door to facilitate close observation due to concerns of off going nurse noting resident with altered mental status. LPN BB documents that she was able to visualize the resident in bed and appears to be watching TV. After receiving report LPN BB writes that she proceeded to begin medication administration at 8::30 p.m. LPN BB documents that she proceeded to the resident's room to administer medication. LPN BB opened the door and visualized the resident on the floor with her head in between the side rail and the mattress with the bilateral bolsters noted to be on the bed. Resident's right leg was parallel with the bed and her left leg was folded under the right leg. The sheets were off to the left side of the bed following the direction in which the resident was positioned on the floor. The head of the resident's bed was elevated and the over bed table was parallel to the bed with Foley catheter bag placed on top of the table. Upon discovering the resident, the nurse called for assistance from other staff members. CPR (cardiopulmonary resuscitation) was initiated and 911 emergency services (EMS) was contacted. Staff continued emergency measures until EMS arrived and took over. EMS responders defibrillated the resident. Law enforcement arrived. Family member and DON (Director of Nursing) notified. Additional review of the nurses 'notes for R#64 did not reveal any documentation of the resident experiencing any changes or altered mental status prior to [DATE]. A review of the facility's investigation report dated [DATE] revealed a memo from the Administrator documenting the resident's admitted to the facility and diagnoses. The Administrator documents that on [DATE], apparently R#64 fell or slid out of bed resulting in death. The memo further indicates the resident placed her Foley catheter on the bedside table prior to getting up unassisted. When the LPN found the resident, her chin was resting on the bottom edge of the quarter side rail with her head partially on the air mattress and her right hand holding the quarter side as to try to attempt to pull herself up. The memo further documents the resident's left hand was braced on the floor leading to the facility to further deduct her attempt to pull herself up. The Administrator documents the resident was unresponsive when the LPN entered the resident's room. Staff performed CPR until the EMS arrived. The incident was investigated by the Sheriff's department and the resident's body transported to the crime lab. The preliminary cause of death a Distraction Injury. The employees verify the last time the resident was alive was 7:15 p.m. during shift report. The facility's investigation lacked documentation as to the control setting of the air mattress at the time of the incident; if the mattress was fully inflated; if air mattress was secured to the bed frame or if there were any gaps between air mattress and side rails; and if the pressure alarm was present and functioning. Interview with LPN AA via telephone on [DATE] at 12:38 p.m. revealed on [DATE] on the day shift R#64 had a change in condition and was not acting like herself. We counted our medication carts and gave report outside her room so we could keep an eye on the resident. LPN AA stated she looked in the resident's room during report and could see her sitting up in bed. The CNA stated she did not eat well for supper. LPN AA stated the resident at times had periods of confusion but the level of the confusion that day was different. The resident stated her sister-in-law wanted her to go to her reception but the resident wanted to wait until her birthday which was two months away, but her sister-in-law said she had to go now. The resident had a fall from the bed prior to this incident. LPN AA stated R#64 had a bolster on the bed that went from the end of the side rail to the end of the bed. She also had a leg brace on. LPN AA stated she would never let the resident transfer herself because she did not have the strength. LPN AA stated she did not make the decision about who had side rails and who did not. LPN AA stated in this area, going to your reception means going to your funeral which is why we were watching her carefully. An attempt to interview LPN AA again via telephone was made on [DATE] at approximately 3:00 p.m. regarding the use of the pressure alarm was unsuccessful and LPN AA did not return the phone call as requested. During an interview on [DATE] at 12:56 p.m., LPN CC stated When I woke R#64 up towards the end of my shift, she was talking about going to her reception and I thought the resident was talking about a dream. LPN CC also stated she did not know talking about having a reception was a funeral. The resident was talking about past family member that had died . LPN CC further stated she had never heard anyone talk like that before so we did report at the door, to keep an eye on her. The resident had quarter side rails, and a brace on her left leg that kept her leg straight all the time. The resident could not get out of bed herself. Review of the nurses' notes and interviews lacked evidence the staff provided increased supervision for this resident with a change in cognition and lacked evidence the facility notified the physician of the resident's change in mental status. Interview with MDS Coordinator EE (identified as the nurse contact during the survey) on [DATE] at 1:20 p.m. revealed the facility did not have a formal side rail assessment. She further stated the nurses, usually the Director of Nursing (DON), Assistant Director of Nursing (ADON) or herself, talk to the residents and see if the resident would benefit from using the side rails/enabler's. We then note the side rails/enabler's on the care plan. R#64 had quarter side rails/enabler's. MDS Coordinator EE did not know if the pressure alarm sounded at the time of fall. Interview with the Administrator on [DATE] at 1:52 p.m. revealed she believed the air mattress was rented and in that case the delivery people would set up the mattress and the settings. Regarding the care plan intervention to deflate the mattress slightly, she did not know how much the DON deflated the mattress and what the new settings were. The facility could not explain why the care plan listed the intervention to deflate the air mattress or the setting of the air mattress. The facility was unable to provide documentation of the initial mattress settings and that the DON had changed the settings. Attempted interview with the Medical Examiner (ME) on [DATE] at 1:54 p.m. via telephone was unsuccessful and the ME did not return the phone call as requested. Interview on [DATE] at 1:58 p.m. with LPN CC stated she had returned to the building around 8:30 p.m. on [DATE]. When she got back to the facility a CNA stated they needed her in R#64's room. When LPN CC entered the room she saw the R#64 between the side rails and the mattress. The resident was on the floor on the left side of the bed by the room door. LPN CC stated she did not hear the bed alarm going off. LPN CC further stated R#64 had a little confusion. An aide had recently reported the resident was talking about a dog or cat in the room (the resident did not have animals in her room). On [DATE] at approximately 2:30 p.m. the Administrator provided the survey team with the type of pressure alarm that was on R#64's bed at the time of the incident. Observation at that time revealed the pressure alarm operated by batteries. An additional review of R#64's record lacked evidence that the facility routinely checked the working condition of the pressure alarm. Interview with the Administrator on [DATE] at 2:35 p.m. revealed the facility did not consider quarter side rails as side rails, they consider them as enabler's. Since this incident the nurses have looked all residents with side rails/enabler's to see if the resident used them. The Administrator stated the staff did not report if the pressure alarm sounded and the investigation did not document the use of the pressure alarm. Interview with the Administrator and Senior Administrator on [DATE] at 6:21 p.m. revealed prior to this incident the nurses decided who received side rails when the residents entered the facility. The Administrator stated there was no formal documentation or form used. The nurses know to only use the side rails for enabling. The Administrator further stated that if a resident had a BIMS of seven (cognitively impaired) but could put her hand on the side rail to turn, we would apply a side rail/enabler to the bed. Review of the facility's policy titled Use of Side rails: dated [DATE] indicated the purposes of these guideline are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. The policy did not include the assessment for the use of the side rails. The Administrator also stated since this incident we have completed bed safety and side rail assessments. The facility also completed an alarm check list to make sure the alarms were working properly. The Administrator stated the DON completed the alarm checks prior to the incident but she threw away the check lists and could only provide the check list starting [DATE]. The Administrator stated a Bed Log is completed by maintenance on at least a weekly basis in which they checked to see if the mattress is compatible with the bed frame and if the bedrails are compatible with the bed frame. The facility also started on [DATE] a weekly Quality Improvement Data Collection Grid in which the facility assesses if a transfer bar is appropriate, if the use of the transfer bar is on the care plan, if the side rail (enabler) is appropriate and if the enabler is on the care plan. The facility also completed an in-service starting on [DATE] regarding use of transfer bars/side rails (enabler's) and fillers and keeping bolsters in place at the head of bed and foot of bed at all times. Interview with the Senior NHA (Nursing Home Administrator) Consultant on [DATE] at 10:20 a.m. revealed that she had received a phone call from the Administrator on [DATE], informing her of R#64's death. NHA Consultant stated that she was unable to enter the resident's room since the sheriff's investigation was in progress. NHA Consultant also stated that she worked with the DON and Administrator investigating the incident, however she admitted the team did not obtain additional statements from the staff on duty and did not interview the staff that was duty on the day shift. NHA Consultant further stated they were working in conjunction with the sheriff's investigation it was not necessary to obtain additional statements. The NHA Consultant stated that when she inspected the resident's room she did not remember seeing the pressure alarm on the resident's bed. The NHA Consultant stated it appears the resident had attempted to get out of bed, as the resident had removed her urinary drainage bag and placed it on the over bed table. It looked like the resident had lost her footing started to slide from the bed and became entrapped between the side rail and air mattress. The NHA Consultant believes the resident attempted to prevent the fall by grabbing the bed rail and bed sheets. The NHA Consultant acknowledged that she did not investigate the issue of the pressure alarm not functioning and that she did write a summary of her investigation according to the facility's policy on abuse investigation. Telephone interview on [DATE] at 11:05 a.m. with CNA FF revealed she was on duty on [DATE] on the ,[DATE] day shift. CNA FF states when she assisted the resident with her breakfast that morning she did not see any type of pressure alarm device on the resident's bed. Interview on [DATE] at 11:20 a.m. with LPN AA revealed she was the nurse assigned to R #64 on [DATE] from 7 a.m. to 7 p.m. LPN AA stated the resident was bedridden and required total assistance with mobility. LPN AA noticed later in afternoon the resident seemed more confused after waking up from a nap. Resident was talking to a dead relative and at times talking to herself. LPN AA felt this was unusual behavior for R #64 and decided to monitor her closely. And reported this behavior to the oncoming nurse, but did not report the resident's altered mental status to the resident's primary care physician. LPN AA also stated the bed pressure alarm was in place and the reset box was positioned on the resident's side rail, but does not know if the pressure alarm was functioning. LPN AA further stated usually the restorative aide during the week checks the pressure alarm to determine if functioning properly. LPN AA also states that approximately two weeks prior to the [DATE] incident, she found the resident laying on the air mattress and it was completely deflated. Upon investigation she found the air mattress was unplugged and once she plugged it in the mattress was re-inflated. LPN AA states that she did not change the mattress settings nor did she report the incident to the Director of Nursing (DON). LPN AA stated she has never receiving any training from the facility on the use of the air mattresses. Interview on [DATE] at 11:45 a.m. with the DON revealed the resident had experienced periods of slight confusion since admission to the facility, but it seemed to occur for short periods of time and then her mental status would return to normal. The DON was unable to provide documentation of the resident's periods of confusion. The DON stated the resident was placed on the air mattress due to her surgical wounds, unstageable pressure to the sacrum and the morbid obesity around the end of May or beginning of June. The DON was present when the resident was placed on the air mattress and adjusted the setting herself. The DON placed the setting on the firmest/highest setting to the resident's morbid (severe) obesity. The DON also stated the staff are instructed if there is a problem with the air mattress to notify the DON or ADON since only they could change the settings on the air mattresses. The DON explained R#64 was found on the floor on [DATE] by the night staff and while investigating the incident the DON determined that maybe the resident's air mattress was too firm and possible caused the resident to slide off the mattress; also, the team did not observe any gaps between the air mattress and the side rails. At that time the investigating team decided to deflate air mattress slightly and add bed bolsters to the air mattresses. The DON reduced the setting to half which she felt was a medium setting and appropriate for this resident's size. These interventions were also added to the care plan. The DON stated the resident was followed in the weekly Incident Reduction meetings. The DON was unable to provide documentation of her changing the setting on the air mattress control setting panel. The DON acknowledged that her investigation did not include the non-functioning pressure alarm. The DON also stated the pressure alarms are checked daily during the week by the restorative aide and documented on alarm checklist sheet and on the weekends the CNAs are responsible for checking the pressure alarms. These sheets are maintained for 30 days and at end of the month the sheets are destroyed. The facility does not have a policy for monitoring the functionality of the pressure alarms. Continued interview with DON regarding the resident's fall on [DATE] revealed the DON received a call from the nursing staff informing her of R#64's death. The DON stated when she arrived at the facility the sheriff's department had secured the resident's room and she was not granted immediate access. After speaking to the sheriff's investigators, the DON interviewed the staff present at the time of the incident. When to asked to provide the statements that she obtained from the staff, the DON referred to the witness statements obtained by the sheriff's investigators. The DON acknowledged that she did not obtain her own statements from the staff and relied on what the sheriff's investigator had obtained; that she did not write an addendum to witness statements to include the information she had gained during her interviews with the staff. The DON also stated once she gained access to the resident's room she observed the pressure alarm on the resident's bed and she touched the alarm and it sounded. The DON assumed it was working at the time of the resident's fall and did not investigate the pressure alarm any further. Interview with the Nursing Home Administrator (NHA) on [DATE] at 12:40 p.m. revealed the NHA along with the DON and NHA Consultant interviewed the staff after the [DATE] incident. The NHA confirmed that she did not obtained additional statements from the staff since the sheriff's investigators had obtained witness statements. The surveyor explained the NHA the difference between a sheriff's investigation compared to a nursing home investigation. The NHA acknowledged that the administrative team interviews with the staff did yield additional information that was not included in their initial statements. However, the NHA also acknowledge the administrative team failed to document any their interviews with the staff. The NHA agreed facility investigation did not follow the facility's abuse investigation procedure. Review of the Officer's Supplemental dated [DATE] at 3:21 a.m. revealed The complainant, advised me that when she went into the room she found {R#64} hanging from the side of her bed. {R#64} head was lodged between the mattress and the bed rail. Further review of the sheriff's office investigation revealed the side rail was 28 and ,[DATE] inches in length and 12 inches in height. The distance to the center was 5 and ,[DATE] inches, the space in the rail was 4 and ,[DATE] inches on the top and 4 and ,[DATE] inches at the bottom. Further review of the facility's investigation revealed copies of employee witness statements taken by the sheriff's department and not by the facility's investigation: Review of Certified Nurse Aide (CNA) DD's written statement dated [DATE] revealed she picked up R#64's supper tray around 6:30 p.m. and the resident was fine. The statement did not include the resident's cognition status, the level of the bed, the position of the resident in the bed, or the use of the pressure alarm. Review of LPN CC's written statement dated [DATE] revealed at 4:39 p.m. she woke R#64 up for medications and accu-check. R#64 was in a good mood and talked about a reception that her and her deceased sister had attended together. LPN CC told R#64 that her blood sugar was elevated (290) and asked the resident what she had for lunch and the resident stated she had cake at the reception. LPN CC sat her up to eat dinner and receive her medication. I left her bedside table across her so she could receive her dinner tray. We spoke briefly about the reception and her sister-in-law. LPN CC told the resident it was a bad dream and LPN CC dreamed about love ones that have passed on, LPN CC also told the resident to pray that her sister-in-law to rest. The resident laughed and talked like she had a visitor in the room and that they were planning to leave together. I exited the room yet stayed outside the door to give report. LPN CC mentioned to the oncoming nurse that the resident was talking about a reception and to see if she thought it was a hallucination or bad dream. Report was given around 7:00 p.m. Review of LPN CC written statement dated [DATE] revealed upon returning back into the building at approximately 8:40 to 8:45 p.m. an aide told me I had just come back in time because the nurse needed my help. The nurse came at that time and told me to come quickly because R#64 had hung herself. LPN CC was assigned to a different hall the unit. Interview on [DATE] at 1:45 p.m. CNA DD revealed she was working the ,[DATE] shift on [DATE]. CNA DD states she noticed the resident was more confused and was attempting to up unassisted from the bed. The CNA also stated she had mentioned this to nurse and was informed the resident was trying to get up because she thought she could still walk. CNA DD further stated that the nurse instructed to assist the resident she was trying to get up. When CNA DD entered the resident's room she observed the resident sitting on the side of the bed. CNA DD stated the bed pressure alarm was in place but was not sounding when she entered the room. The CNA further stated she was not responsible for checking if the bed pressure alarm was working and she nor report her observation of the alarm non-functioning to the nurse. Interview on [DATE] at 4:30 p.m. with LPN BB revealed on [DATE] the last time she saw R #64 was at 7:15 p.m. during shift report. Although the off going nurse reported the resident had altered mental status she did not feel the need to assess the resident's mental status. LPN BB also confirmed that she did not instruct assigned CNA to closely monitor the resident for continued confusion. LPN BB stated when she returned to the resident's room at 8:30 a.m. for medication administration she found the resident on the floor trapped between the side rail and air mattress. LPN BB also stated the bed pressure alarm was in place but was not sounding when she entered the room. LPN BB further stated she was not aware of any mechanical problems with the air mattress or pressure alarms. LPN BB confirmed that she did not check the resident's air mattress for proper inflation and if it was secured to the bed frame or if the pressure alarm was functioning properly. LPN BB stated that she has never receiving training on the use of the air mattress and how to ensure it is fitted properly to the bed frame. Telephone interview on [DATE] at 10:07 a.m. with CNA GG revealed the CNA was assigned to R#64 on the evening shift on [DATE]. CNA GG stated that when she picked up the resident's dinner tray from her room the resident seemed alright and did not remember seeing the pressure alarm on the resident's bed. CNA GG further stated when she received the assignment the nurse did not inform her the resident had altered mental status and required close observation. If she had received this information about R#64 she would have checked on the resident sooner. During a telephone interview with the Medical Examiner (M.E.) on [DATE] at 1:00 p.m. the M.E. stated the resident sustained [REDACTED].E. stated after examining the crime scene photographs it would appear as the resident slid from the air mattress, the resident attempted to catch herself by grabbing on the side rail. Unfortunately, the resident's morbid obesity caused a momentum in her sliding off the air mattress to the point where the resident could not avoid becoming entrapped between the mattress and side rail. The force of the fall jerked the resident's head onto the air mattress and her chin was caught upward facing the ceiling causing her to become entrapped. The force of the fall caused a separation of the cervical spine at the fifth and sixth disc and a complete rupture anterior ligament at the same level. The resident's death was instantaneous. The M. E. also stated it was possible that since the air mattress was not fully inflated for someone her size this could have also contributed to the resident's fall. Review of an undated facility document titled

Based on record review and interview with the Administrator the facility failed to identified quality deficiencies and implement and monitor action plans to correct concerns identifying . This failure negatively impacted the quality of resident care. Resident #64 fell on [DATE] and again on [DATE] which resulted in death. The Quality Assurance program did not lend itself to the identification of concerns regarding malfunctioning alarms and mattresses that did not fit bed frames. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to resident(s). The facility's Administrator, Director of Nursing Services was informed of the immediate jeopardy on [DATE] at 2:15 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE], the date a resident (R#64) had fallen from the bed. The facility failed to thoroughly investigate the fall, the resident had a second fall on [DATE], which was fatal. Review of the facility's incident report [DATE] revealed Resident (R ) #64 sustained a non-injurious fall from the bed which had an air mattress on it. The incident report completed by the staff identified that the pressure alarm on the resident's bed did not sound during the incident. The facility failed to conduct a root analysis of this fall incident and put interventions into place that would address the non-functioning pressure alarm and a monitoring system of the air mattress. Review of the nurses' notes dated [DATE] revealed R#64 slipped or fell from her/his air mattress bed and became entrapped between the side rail and air mattress and expired. The facility's investigation failed to identify if the resident's bed pressure alarm was functioning at the time of the incident and how the resident became entrapped between the side rails and air mattress. The facility failed to assess side rails and to conduct their own investigation of the [DATE] incident and relied on statements obtained by the sheriff's department. According to the facility's written policy the investigation did not include witness statements from the staff on duty at the time of the incident and prior to the incident. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D, while the facility continued management level staff oversight of physician notification of changes in resident's condition or any incidents and documentation; resident assessments with changes in condition and after incidents; care plan revision and following the care plan interventions; supervision to prevent accidents (monitoring residents on specialty air mattresses; use and functionality of pressure alarms. Finding include: Review of the facility's Quality Committee Minutes dated [DATE] approximately three weeks after the [DATE] incident revealed the following: The Safety report addressed emergency fire drills, drills on lost person, PT in-service on good body mechanics, installation of new cabinets and other facility constructing, and one incident of needle stick. The Nursing Report addressed the continuation of checking the narcotic blood documentation against the documentation in the electronic Medication Administration Record [REDACTED]. Incidents involving R #64 and an elopement resident was discussed with the Medical Director. The QA meeting did not address assessing the specialty air mattresses to ensure the mattresses were appropriately fitted to the bed frames and the issue of the non-functioning pressure alarms was not addressed. Telephone interview with the Medical Director on [DATE] at 2:20 p.m. revealed the Medical Director was unaware of the incident that occurred with R #64 until the QA meeting on [DATE]. Interview with the Director of Nursing on [DATE] at 4:00 p.m. revealed she had attended the QA meeting on [DATE]. The committee discussed the incident involving R #64 and the interventions put in place to prevent that type incident from reoccurring again. The DON stated the Maintenance Director was responsible for checking the residents on the specialty air mattresses to ensure their safety, however, the DON acknowledged the committee minutes did not reflect that this was being done. The DON also acknowledged the problem regarding the non-functioning pressure alarms was not addressed in the committee meeting. Interview with the QAPI ( Quality assurance and performance improvement) Nurse on [DATE] at 1:30 p.m. the QAPI Nurse was new to the position. The QAPI Nurse stated that she was familiar with the incident involving R #64 and knew the facility had developed interventions to prevent a reoccurrence of the incident. However, the QAPI Nurse was not aware of the concern regarding the safety of the residents using specialty air mattress that should have been discussed in QA. The QAPI nurse further stated that she was unaware there a problem with pressure alarm not sounding with the incident involving R#64 . The QAPI Nurse agreed those two issues should have been addressed in the QA meeting. The QA Meeting that occurred on [DATE], the facility failed to demonstrate systematic identification, reporting, investigation , analysis and prevention of an adverse events . Also, documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities related to the death of R#64 that occurred on [DATE]. S/S J Cross Reference to F323 The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: 1. Record review revealed R#64 no longer resides in the facility. The facility currently has three residents (R#1, #4 and #42) that utilizes specialty air mattresses and no residents are utilize a pressure alarm. 2. On [DATE] The Quality Assurance/Performance Improvement Plan was reviewed by Administrator and DON with no changes noted. It was identified that the problem with pressure alarms, assessing the resident's need and safety of side rails or transfer bars, not obtaining a consent form for side rails or transfer bars prior to use and specialty air mattress to include the need to ensure the correct setting per manufacture recommendation, pressure alarms to include monitoring to ensure they were fully functioning and to the alarm had a working battery, was not presented to the QA Committee. Although, it was discussed in the QA Committee Meeting that all side rails or transfer bars were assessed for appropriate use; no documentation was noted in the resident's chart. 3a. Telephone interview with the Medical Director on [DATE] at 2:2 p.m. in the Administrator's office revealed the Medical Director was unaware of the incident that occurred with R #64 until the QA meeting on [DATE]. 3b. Interview with the QAPI (Quality Assurance and Performance Improvement) Nurse on [DATE] at 1:30 p.m. in the surveyor's work room revealed the QAPI Nurse was new to the position. The QAPI Nurse stated that she was familiar with the incident involving R #64 and knew the facility had developed interventions to prevent a reoccurrence of the incident. However, the QAPI Nurse was not aware of the safety concerns regarding the use of specialty air mattress's that should have been discussed in QA. The QAPI nurse further stated that she was unaware there was a problem with pressure alarms not sounding with the incident involving R#64. The QAPI Nurse agreed those two issues should have been addressed in the QA meeting. The QAPI Nurse plans to work closely with the administrative team to develop and review assessment tools, evaluate programs and make changes as necessary to improve programs and assuring compliance with regulatory requirements, assisting department directors in developing and implementing appropriate plans of action to correct identified deficiencies. The QAPI Nurse further stated it will be her responsibility to review the audit tools to ensure the staff's adherence to the new policies and procedures. The QAPI committee will evaluate various reports to help define issues, plan and implement actions and ensure monitoring and follow-up. 3c. Interview with the DON on [DATE] at 4:30 p.m. revealed the QA Committee was aware of the fatal [DATE] incident involving R#64. Several of the committee members were aware of the incident within 48 hours after occurrence. However, the DON was not sure if the Medical Director was aware of the incident and could not confirm if the Medical Director had been contacted regarding the incident. The QA Committee had a scheduled meeting on [DATE], almost 4 weeks after the incident. A corrective action plan was developed prior to the [DATE] meeting. In the [DATE] meeting the committee discussed the facility's compliance with the current corrective action plan. The DON acknowledged the [DATE] QA meeting did not address issue of monitoring and putting a system in place to ensure the safety of the three residents on specialty air mattresses and the non-functioning pressure alarms. The DON also acknowledge the committee was not made aware of R #64's altered mental status and the resident's [DATE] fall. Because of this survey the facility has instituted new policies and procedures regarding notification, assessments care plan interventions, investigation procedures for incident, monitoring systems for residents on specialty air mattresses. The facility has developed audit tools which will monitor the staff adherence to the new policies and procedures. The facility has a new QA Coordinator who will be responsible for reviewing the audit tool and determining the facility compliance with the AoC for the deficient practices identified during the survey. 4. A review of the facility's in-service attendance sheets revealed training started on [DATE] through [DATE] revealed the facility has provided training according to their AoC. The facility has included all new policies and checklist as a part of the orientation process. 5. During orientation, all new staff will be in-serviced on the QA/PI process which include the identification or areas of concern, resolve present and potential negative outcomes related to resident care and safety by either the DON, ADON or LPN Charge Nurse Supervisor. 6. The last QA/PI meeting was held on [DATE]. The next scheduled QA Meeting is planned to be held on [DATE]. The Quality Assurance/Performance Improvement Committee will meet monthly for the next 6 (six) months to ensure all systems are in place. If no problems are identified, the QA/PI Committee will return meeting every other month.