Every finding on record at Dexter House Healthcare

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#95) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, for Resident #95 the facility failed to ensure nursing scheduled medications around his/her dialysis days. Findings include: Review of the facility policy titled, End Stage Renal Disease, dated as revised July 2023, indicated the facility assures that each resident receives care and services for provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. Resident #95 was admitted to the facility in September 2023 with diagnosis including acute on chronic diastolic heart failure, end stage renal disease, and benign prostate hypertrophy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/3/25, indicated that Resident #95 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #95 required dialysis. Review of Resident #95's nursing note, dated 7/24/25, indicated new dialysis schedule on Monday, Wednesday, and Friday. Review of Resident #95's nursing progress noted, dated 7/29/25, indicated:-Resident is starting new dialysis center on Wednesday. New Schedule starting Monday, Wednesday, Friday. Review of Resident #95's physician's orders, dated 7/30/25, indicated: -Dialysis on Monday, Wednesday, and Friday at 6:00 A.M., scheduled at 6:00 A.M. Review of Resident #95's physician's orders, dated 9/11/24, indicated:-metoprolol succinate extended-release (ER) tablet, give 12.5 milligrams (mg) one time a day every Monday, Wednesday, Friday, and Sunday. Further review of the order indicated for the medication to be administered at 8:00 A.M. Review of Resident #95's Medication Administration Record, dated September 2025, indicated on 9/1/25, 9/3/25, 9/5/25, 9/8/25, 9/10/25, 9/12/25, 9/15/25, 9/17/25, 9/19/25, 9/22/25, and 9/24/25, nursing did not administer the metoprolol as ordered and documented the medication as out of facility. Review of Resident #95's physician's orders, dated 5/31/25, indicated: -Isosorbide Mononitrate ER tablet, give 15 milligrams (mg), one time a day for atherosclerotic heart disease. Further review of the order indicated for the medication to be administered daily at 8:00 A.M. Review of Resident #95's Medication Administration Record, dated September 2025, indicted on 9/1/25, 9/3/25, 9/5/25, 9/8/25, 9/10/25, 9/12/25, 9/15/25, 9/19/25, 9/22/25, and 9/24/25, nursing did not administer the medication and documented as out of facility. Review of Resident #95's plan of care related to dialysis, dated as revised 9/9/25, indicated:-Administer/monitor effectiveness of medications of medications as ordered.-Dialysis on Monday, Wednesday, and Friday at 6:00 A.M. During an interview on 9/25/25 at 9:40 A.M., Nurse #4 said that antihypertensives should not be given prior to dialysis but should be scheduled to be administered on non-dialysis days. During an interview on 9/25/25 at 9:44 A.M., Resident #95 said that he/she goes to dialysis on Mondays, Wednesdays, and Fridays. Resident #95 said that his/her blood pressure sometimes goes below 100 (hypotensive) during dialysis, and the staff need to lay him/her down during dialysis treatment. Resident #95 said he/she should not get blood pressure medications prior to dialysis, and he/she should take them on non-dialysis days. During an 9/25/25 on 10:26 A.M., the Nurse Practitioner said that Resident #95 takes the isosorbide for heart disease and the management of chest pain, and the metoprolol is administered for cardiomyopathy, and she said that nursing should administer these medications around the dialysis schedule. During an interview on 9/25/25 at 11:11 A.M., the Director of Nursing (DON) said cardiac medications are important for Resident #95 and the isosorbide and the metoprolol should be given around the dialysis schedule. The DON said that the nurses who documented the resident was out of the facility should have updated the providers and make obtain new orders with Resident #95's dialysis schedule.

Based on observation and interview, the facility failed to properly follow food storage and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to properly store food items in the kitchen to prevent the risk of foodborne illness.Findings include:Review of the facility policy titled Food and Supply Storage, dated and revised June 2018, indicated the following:- Labeling and rotating food supply:- Refrigerated Time/Temperature Control for Safety Food, ready-to-eat food prepared on site that is held longer than 24 hours should be properly labeled with the common name, the preparation date (day 1) and use-by date (maximum 7 days)- Discard food that exceeds their use-by date or is spoiled.During the initial walkthrough of the kitchen on 9/24/25 at 7:01 A.M., the surveyor observed the following:- In the walk-in refrigerator:- A box of bell peppers with white and black spots that resembled mold and were soft to the touch.- A box of three cucumbers that were covered in white spots resembling mold that were shriveled and very soft to touch.- A container of cantaloupe melon with a melon having a dark black spot resembling mold, it was very soft to touch.- A container labeled [NAME] Crackers with no packaged date or use by date.- A container of Chocolate Frosting with only one date of 9/20.- An opened bag of shredded cheese with only one date of 9/16.- In the Reach-in Refrigerator:- Three pre-poured jugs containing what resembled juice, there were no labels of what the item was or any dates.- A container of Apple Sauce with a use by date of 9/22.During the re-visit to the kitchen on 9/25/25 at 7:38 A.M., the surveyor observed the following:- A box of bell peppers with white and black spots that resembled mold and were soft to the touch.- A box of three cucumbers that were covered in white spots resembling mold that were shriveled and very soft to touch.- A container of cantaloupe melon with a melon having a dark black spot resembling mold, it was very soft to touch.- A container labeled [NAME] Crackers with no packaged date or use by date.- A container of Chocolate Frosting with only one date of 9/20.During an interview on 9/25/25 at 7:47 A.M., the Foodservice Director said all prepared and opened foods should be labeled as what they are and have two dates, the prepared date and the use-by date. The Foodservice Director then said the produce should have been discarded after observing it with the surveyor.

Based on observations, interviews, and record reviews for three Residents (#70, #46, and #34) out of five residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of four nurses observed made four errors out of 25 opportunities resulting in a medication error rate of 16%. Specifically,a.) For Resident #70, Nurse #1 administered the incorrect form of multiple vitamin.b.) For Resident #46, Nurse #2 administered the incorrect form of aspirin, and she did not follow manufacture's recommendations and crushed a medication that indicated do not crush. c.) For Resident #34, Nurse #3 administered an enoxaparin (medication used for blood clot prevention) injection intramuscularly (by holding the needle at a 90-degree angle into the muscle, allowing rapid absorption into the blood stream) into the vastus lateralis muscle (outer side of the thigh, part of the quadriceps muscle) instead of subcutaneously (injecting into pinched skin at a 90-degree into the fat) in accordance with the physician's orders. Findings include:Review of the facility policy titled, Administering Medications, dated as revised September 2024, indicated medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation b. Medications are administered in accordance with prescriber's orders.e. The individual administering medications checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. a.) On 9/24/25 at 8:44 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #70. Nurse #1 administered the following:-one Multiple Vitamin tablet. Review of Resident #70's physician's order, dated 1/30/25, indicated for nursing to administer one tablet of multiple vitamins with minerals. During an interview on 9/24/25 at 1:42 P.M., Nurse #1 she didn't have multiple vitamins with minerals on her medication cart, and she gave the Resident a standard multiple vitamin without minerals. Nurse #1 checked the medication storage room with the surveyor, and she said there were no multiple vitamins with minerals available. During an interview on 9/24/25 at 3:19 P.M., the Director of Nursing (DON) said that nursing should have obtained the correct multiple vitamins. b.) On 9/24/25 at 8:58 A.M., the surveyor observed Nurse #2 prepare and administer mediations to Resident #46. Nurse #2 crushed and administered the following: -aspirin 81 milligrams (mg) enteric coated, and-Carbidopa-Levodopa Extended Release 50-200 mg. Review of Resident #46's physician's orders indicated the following:-aspirin 81 mg chewable tablet, dated 11/24/24. Not the enteric coated aspirin Nurse #2 administered. -Carbidopa-Levodopa Extended Release (ER) 50-200 mg. Review of the medication card indicated, HIGH ALERT, DO NOT CRUSH OR CHEW. During an interview on 9/24/25 at 1:59 P.M., Nurse #2 said that she should have administered the correct aspirin, and she should have followed the manufactures directions and not crushed Resident #46's Carbidopa-Levodopa ER tablet. During an interview on 9/24/25 at 3:21 P.M., the Director of Nursing said the nursing should have administered the correct aspiring and she should have not crushed the Carbidopa-Levodopa ER tablet. c.) On 9/24/25 at 9:15 A.M., the surveyor observed Nurse #3 prepare and administer medications for Resident #34. Nurse #3 administered one injection of enoxaparin intramuscularly into Resident #34' right vastus lateralis muscle. Nurse #3 held Resident #34s skin taught and she injected the enoxaparin injection into the muscle. Nurse #3 said enoxaparin should be administered intramuscularly. Review of Resident #36's physician's order, dated 1/29/25, indicated:-enoxaparin sodium solution 40 milligrams (mg), give 40 mg subcutaneously one time a day for prevent blood clotting. During an interview on 9/24/25 at 1:54 P.M., Nurse #3 said she should have administered Resident #34's enoxaparin injection subcutaneously into his/her abdomen and not intramuscularly into his/her thigh. During an interview on 9/24/25 at 3:22 P.M., the Director of Nursing said that Nursing should have administered Resident #34 the enoxaparin injection subcutaneously into the abdomen.

Based on observation and interview, the facility failed to properly store and dispose of medication on one unit. Specifically, a medication was found behind a broken radiator that was easily accessible to the residents on the unit. Findings include:During an observation on 9/24/25 at 8:55 A.M., a large white pill was found on the floor behind a broken radiator in the hallway on the B unit. The pill was easily accessible to residents wandering on the unit and was outside of the door to one resident's room. The surveyor notified the nurse on the unit and she said that the medication looked like Atorvastatin (a medication used to lower cholesterol), but that she could not be positive that was the medication. The nurse said she would dispose of the medication immediately. During an interview on 9/26/25 at 10:09 A.M., the Director of Nursing said that if a medication is found on the floor in the hallway then the nurse should try to identify where the pill came from and then destroy the pill. She said there should not be a medication on the floor in the hallway and there is a risk that a resident could pick up the pill and ingest it.

Based on observations, record review, and interviews, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula) was provided according to professional standards for two Residents (#36, #8) out of a total sample of 25 Residents. Specifically, the facility failed to ensure a tube feeding was labeled and dated when opened for Residents #38 and #8.Findings include: 1.Resident #36 was admitted to the facility in January 2025 with diagnoses including cerebral infarction, diabetes, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/25, indicated that Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #36 did not eat, had a feeding tube in place, and required tube feeding. On 9/24/25 at 7:48 A.M., the surveyor observed an open bottle of tube feeding without a date. The bottle of tube feeding indicated the following precautions: -Feeding sets are for single patient use only. -Hang product for up to 48 hours after initial connection when clean technique and only one new feeding set is used. Otherwise, hang no longer than 24 hours. -Use by date on container. On 9/24/25 at 9:35 A.M., the surveyor observed Nurse #36 administer tube feeding formula from an opened an undated tube feeding bottle on the bedside table. Review of Resident #36's physician's order, dated 3/12/25, indicated: -Enteral feed five times day. Glucerna 1.2, bolus (a type of tube feeding administration) 240 cc (milliliters) 5x/day at 6:00 A.M., 10:00A.M., 2:00 P.M., 6:00 P.M., and 10:00 P.M., total volume 1200 milliliters. During an interview on 9/24/25 at 9:36 A.M., Nurse #3 said that Resident #36's tube feeding bottle was opened and undated when she administered the feeding and she said she assumed it was opened by the night nurse, but she was not certain. Nurse #3 said that bottles of tube feed should be dated when opened and used by the expiration date. During an interview on 9/24/25 at 3:29 P.M., the Director of Nursing said that nursing should date and label tube feedings according to manufacturer's directions. During an interview on 9/24/25 at 3:45 P.M., the Director of Clinical Operations said that the facility did not have a policy on enteral feeding administration. 2. Resident #8 was admitted to the facility in May 2025 with diagnoses including acute and chronic respiratory failure with hypoxia, dysphagia and hemiplegia/hemiparesis. Review of Resident #8's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating that the resident is severely cognitive impaired, further review of the MDS indicated that the Resident is currently receiving tube feeding therapy and is dependent on staff for all activities of daily living. The surveyor made the following observation: - On 9/25/25 at 8:14 A.M., Resident #8 was sleeping in his/her bed receiving enteral nutrition via a feeding tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula). The tube feeding pump was powered on indicating that Resident #8 was receiving tube feeding formula. The tube feeding bag failed to have any identification of what type of formula or the date and time it started. Review of Resident #8's physician's orders indicated the following: - Enteral Feed order: two times a day Nutren 2.0 (an enteral tube feeding formula) cal (calorie) 35 ml/hr (milliliters/hour) for 18 hrs (hours) (7pm-1pm) for total of 630 ml daily – Ordered 5/19/25 - Enteral Feed Order: every shift via Automatic flush by enteral feed pump – give free H2O (water) 50ml every 1 hours x 18 hrs 7pm-1pm – Ordered 9/22/25 Review of Resident #8's Nutrition care plan indicated the following intervention dated 2/15/25: Provide enteral nutrition as ordered. During an interview on 9/25/25 at 8:26 A.M., Nurse #7 said when residents are receiving tube feeding formula, the opened bags need to be labeled and dated so staff members know what each resident is receiving. Nurse #7 and the surveyor observed Resident #8's tube feeding bag and Nurse #7 said it is not labeled nor dated and it should be. During an interview on 9/25/25 at 9:12 A.M., the Director of Nursing said all tube feeding bags need to be labeled and dated so staff know what the solution is and when it was hung and what rate of feeding the Resident is receiving.

Based on observations, record review and interview, the facility failed to follow recommendations of the wound doctor and implement the plan of care for one Resident (#110) out of a total sample of 25 Residents. Specifically, the facility failed to ensure Resident #110's feet were offloaded as recommended by the wound doctor and the plan of care.Findings include:Review of the facility policy titled Prevention and management of Pressure Ulcers/Injuries, dated and revised November 2024, indicated the following:- Develop the resident-centered care plan and interventions based on the risk factors identified, the condition of the skin, the resident's overall clinical condition.Resident #110 was admitted to the facility in July 2025 with diagnoses including fracture of the left femur and chronic obstructive pulmonary disease.Review of Resident #110's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #110 was at risk of developing pressure ulcer/injuries, has unhealed pressure ulcers/injuries including one unstageable pressure ulcer, does not reject care and requires staff assistance with all activities of daily living.The surveyor made the following observations:- On 9/24/25 at 7:45 A.M., Resident #110 was sleeping in his/her bed with his/her right foot wrapped in a bandage. Both the Resident's left and right foot were directly on the mattress. No pillow or device were present to offload his/her feet.- On 9/25/25 at 6:54 A.M, 8:21 A.M., 10:45 A.M. and 1:17 P.M, Resident #110 was lying in his/her bed with his/her right foot was wrapped in a bandage. Both the Resident's left and right foot were directly on the mattress. No pillow or device were present to offload his/her feet.Review of Resident #110's potential alteration in skin integrity care plan indicated the following interventions dated 7/17/25: Follow MD (medical doctor) orders for skin care and treatments, heels offloaded when in bed.Review of Resident #110's Norton Scale for Predicting Risk of Pressure Ulcers dated 9/23/25 indicated that the Resident is at risk for developing pressure ulcers.Review of Resident #110's Wound Evaluation and Management Summary dated 9/23/25, performed by the wound doctor, indicated the following:- Unstageable deep tissue injury with an etiology of pressure on the left heel, approach: off-loading. Additional Wound detail: Recommend aggressive offloading/repositioning.Review of Resident #110's physician's orders failed to indicate an order for Resident #110 to offload his/her feet.During an interview on 9/26/25 at 9:03 A.M., Nurse #1 and the Assistant Director of Nursing (ADON) said Resident #110's feet should be elevated while he/she is in bed and the recommendations from the wound doctor should be followed as well as the care plans.During an interview on 9/26/25 at 10:02 A.M., the Director of Nursing (DON) said Resident #110's feet should be elevated when he/she is in bed if that is what the wound doctor recommended so his/her pressure ulcers do not worsen.

Based on observation, record review and interview, the facility failed to ensure standards of quality of care were implemented for one Resident (#110) out of a total sample of 25 residents. Specifically, the facility failed to ensure a treatment was in place for a non-pressure wound of the left, first toe and ensure the treatment orders were completed as written.Findings include:Review of the facility policy titled Prevention and management of Pressure Ulcers/Injuries, dated and revised November 2024, indicated the following:- Develop the resident-centered care plan and interventions based on the risk factors identified, the condition of the skin, the resident's overall clinical condition.Resident #110 was admitted to the facility in July 2025 with diagnoses including fracture of the left femur and chronic obstructive pulmonary disease.Review of Resident #110's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #110 was at risk of developing pressure ulcer/injuries, has unhealed pressure ulcers/injuries including one unstageable pressure ulcer, does not reject care and requires staff assistance with all activities of daily living.The surveyor made the following observations:- On 9/24/25 at 7:45 A.M., Resident #110 was sleeping in his/her bed and his/her left foot was visible. On his/her left first toe was a scabbed and open area about the size of a dime. No treatment was in place.- On 9/25/25 at 6:54 A.M, 8:21 A.M., 10:45 A.M. and 1:17 P.M, Resident #110 was lying in his/her bed with his/her left foot visible. On his/her left first toe was a scabbed, open area about the size of a dime. No treatment was in place.- On 9/26/25 at 6:50 A.M., Resident #110 was sleeping in his/her bed with his/her left foot visible. On his/her left first toe was a scabbed, open area about the size of a dime. No treatment was in place.Review of Resident #110's Wound Evaluation and Management Summary dated 9/23/25, performed by the wound doctor, indicated the following:- Non-Pressure wound of the left, first toe with an etiology of trauma/injury.- Dressing Treatment Plan: Primary Dressing - A+D (an ointment that goes on the skin) apply once daily and as needed. For 30 days; Gauze sponge non-sterile apply once daily and as needed. Secondary Dressing - Gauze roll 4.5 apply once daily and as needed for 30 days.Review of Resident #110's Skin Integrity Care Plan indicated the following intervention dated 7/15/25: Consult and treatment by Wound MD (medical doctor) or Certified Wound Nurse PRN (as needed) and as ordered.Review of Resident #110's Norton Scale for Predicting Risk of Pressure Ulcers dated 9/23/25/ indicated that the Resident is at risk for developing pressure ulcers.Review of Resident #110's physician's orders dated 9/23/25 indicated the following order:- L (left) 1st toe- A & D, gauze, and tape daily AMT (amount): SC = Scant, SM = small, M = Medium, L = large. DRN (drainage): C = clear, SS = serosang, S = serous, P = purulent. WB: G = granulation, S = slough, N = necrotic. SAW: I = intact, P = pink, E = Erythema, M = moist, D = dry. OUT: B = better, W = worse, NC = no change. Change every shift.Review of Resident #110's Treatment Administration Record for September 2025 failed to indicate that the above parameters were being documented and each date was only documented with a check mark, but did not acknowledge the written parameters as ordered.During an interview on 9/26/25 at 9:03 A.M., Nurse #1 and the Assistant Director of Nursing (ADON) said Resident #110's treatment orders for his/her left toe should have been implemented since they were recommended by the wound doctor. The ADON then said when she input the order to track the progress of Resident #110's left toe wound, it got input wrong resulting in no place for staff to document the progress of the wound.During an interview on 9/26/25 at 10:02 A.M., the Director of Nursing (DON) said Resident #110's treatment orders should be followed so his/her wound does not worsen, and the Resident's treatment order needs to be updated so the treatment parameters can be documented by staff.

Based on observations, record review and interviews, the facility failed to ensure one Resident (#84) was assessed for and free from restraints out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #84 was free from a restraint in the form of bolsters that ran from the head of the bed to the foot of the bed on both sides to keep the Resident in bed.Findings include:Review of the facility's policy titled Use of Restraints, dated and revised January 2024, indicated the following:- Guidelines: Prior to placing a resident in restraints, there shall be a pre-restraining evaluation and review to determine the need for restraints. The evaluation shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms.- Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Resident #84 was admitted to the facility in April 2025 with diagnoses including unspecified fracture of the right humerus, type 2 diabetes mellitus and Alzheimer's disease.Review of Resident #84's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 1 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires substantial/maximum assistance from staff for activities of daily living and partial/moderate assistance when transferring out of bed.The surveyor made the following observations:- On 9/24/25 at 7:51 A.M., Resident #84 was sleeping in his/her bed. On the left and right side of the bed, bolsters were observed to be tucked under Resident #84's sheet and running from the head of the bed to the foot of the bed, covering the length of the Resident in bed.- On 9/25/25 at 8:34 A.M., Resident #84 was eating his/her breakfast in bed. On the left and right side of the bed, bolsters were observed to be tucked under Resident #84's sheet and running from the head of the bed to the foot of the bed, covering the length of the Resident in bed.- On 9/25/25 at 1:22 P.M., Resident #84 was not in his/her bed. Beside his/her bed were fall mats on the floor, on top of the fall mats were two bolster pads.Review of Resident #84's physician's orders does not indicate an order for the use of bed bolsters.Review of Resident #84's falls care plan indicated the following intervention dated 5/22/25: Scoop Mattress, requested by the family.Review of Resident #84's fall care plan and all active care plans, failed to indicate the use of bed bolsters.Review of a progress note written by the Nurse Practitioner dated 5/30/25 at 10:35 P.M., indicated the following but is not limited to: Patient continues with poor safety awareness with multiple attempts to get out of bed without help. He/she is on a scoop mattress to help deter self-transfers from bed.Review of Resident #84's medical record failed to indicate an assessment for the use of any restraint including bed bolsters or a scoop mattress.During an interview on 9/26/25 at 7:11 A.M., Certified Nursing Assistant (CNA) #1 said Resident #84's mattress has raised edges because he/she is a fall risk, and he/she tries to swing his/her legs over the bed, and the edges help keep him/her in bed.During an interview on 9/26/25 at 7:13 A.M., Nurse #6 said Resident #84 has bolsters on his/her bed by his/her family's request. Nurse #6 said bolsters need to be assessed for the use as a restraint because Resident #84 should be able to get out of bed if he/she wants to. Nurse #6 and the surveyor observed Resident #84 in bed, Nurse #6 lifted Resident #84's sheet and observed the bolsters in place.During an interview on 9/26/25 at 9:13 A.M., the Assistant Director of Nursing (ADON) said Resident #84's family brought in the bed bolsters and have been putting them under the sheets. The ADON then said the facility should have completed a restraint assessment as the bolsters are a potential restraint. The ADON and the surveyor reviewed Resident #84's medical record and did not identify a restraint assessment or evaluation.During an interview on 9/26/25 at 10:02 A.M., the Director of Nursing (DON) said a restraint assessment should have been completed before the use of bed bolsters for Resident #84.

Based on record review and interview, the facility failed to obtain informed consent from the responsible party of one Resident (#11) out of a total sample of 25 residents. Findings include:Review of the facility policy titled Pyschotropic Medication, revised 07/2023, indicates the following: A written informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. Resident #11 was admitted in February 2023 with diagnoses including dementia and psychotic disorder with delusions. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #11 scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the physician's orders for Resident #11 indicated that he/she has active orders for the medications Risperdal (an antipsychotic medication used to treat Schizophrenia) and Fluoxetine (a psychotropic medication used to treat depression). Review of the psychotropic consent administration forms for Fluoxetine and Riperdal indicate that both were signed on 11/4/24 by Resident #11. Review of the health care proxy invocation form indicated that Resident #11's health care proxy was invoked on 8/1/22, indicating that Resident #11 could no longer make his/her own decisions due to dementia. During an interview on 9/25/25 at 11:07 A.M., the Director of Nursing said that Resident #11 should not be signing his/her own consents for medication if he/she has an invoked health care proxy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure he/she was free from a significant medication error, when on 08/07/25, Nurse #1 administered Epinephrine (hormone that increases adrenaline) to him/her instead of Glucagon (hormone that increases blood glucose level), in error.Findings include: The Facility Policy, titled Administering Medications, dated as revised 09/2024, indicated, the individual who administered medications would check the label to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. Resident #2 was admitted to the Facility in July 2025, diagnoses included left femur fracture, hypertension, and diabetes.Review of Resident #2's Hospital Discharge summary, dated [DATE], indicated that on 08/07/25, while at the Facility, Resident #2 experienced a change in mental status, was assessed by nursing, and found to have a blood glucose level of 59 milligrams/deciliter (mg/dl) (low). The Hospital Discharge Summary indicated that the Facility nurse attempted to administer a Glucagon injection, however, administered an EpiPen injection, by mistake.Review of Resident #2's Order Summary Report indicated he/she had a Physician's order, dated 07/08/25, to administer Glucagon (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels by increasing glucose concentration in the bloodstream) 1 milligram (mg) intramuscularly (IM) as needed for blood sugar less than 70 mg/dl if he/she was not responsive or not able or willing to swallow.Further review of Resident #2's Order Summary indicated he/she did not have a physician's order for Epinephrine.Review of the Facility's Emergency Kit Contents List, located one kit on each unit, indicated the kit contained the following:-Gvoke (Glucagon) 1mg per 0.2ml Hypopen injection.-Epinephrine (EpiPen, also known as adrenaline, is both a neurotransmitter and a hormone. It plays an important role in your body's fight-or-flight response. It's also used as a medication to treat many life-threatening conditions) 0.3mg per 0.3 milliliters (ml) injection.According to Mayoclinic.org, serious side effects of Epinephrine include increased blood pressure, which can lead to heart attack or stroke, as well as vomiting, tremors, and seizures. During an interview on 09/02/25 at 03:44 P.M., Nurse #1 said that on 08/07/25 at 10:00 P.M., she was alerted by another staff member that Resident #2 had a change in mental status and was shaking. Nurse #1 said Resident #2's blood glucose level was 59 mg/dl (low). Nurse #1 said she used her cell phone to call 911 while she tried giving him/her orange juice with sugar mixed in it, however he/she was unable to drink it. Nurse #1 said she then was instructed by the 911 dispatcher to administer Glucagon. Nurse #1 said she was unable to unlock the medication room door, which was where the Emergency Kit for that unit was located, and ran upstairs to another unit to get the Glucagon from their kit. Nurse #1 said the nurse on the other unit handed her Glucagon and an EpiPen, and she went back to Resident #2's room. Nurse #1 said she opened and read the instructions for the Glucagon, but when she administered the injection, she reached for, opened, and administered the EpiPen, by mistake. Nurse #1 said she was unaware that she had made the medication error until the following day, when the Administrator called her.During an interview on 09/02/25 at 01:52 P.M., The Director of Nurses (DON) said Nurse #1 should have ensured she administered the correct medication but did not.On 09/02/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 08/09/25, which addressed the area(s) of concern as evidenced by:A. 08/08/25, Resident #2 was readmitted to the Facility and had no ill effects as a result of the medication error that occurred on 08/07/25.B. 08/08/25, The ADON conducted a medication administration skills observation with Nurse #1.C. 08/08/25, The Ad-Hoc Quality Assurance Performance Improvement Action Plan indicated the Facility Leadership developed a plan to correct the deficient practice and ensure that residents were free from significant medication errors.D. 08/08/25, The DON and ADON educated all licensed staff on medication administration best practices, with focus on the Emergency Supply Kit review.E. 08/08/25, The DON and ADON began random medication pass observations with licensed staff.F. The DON and/or ADON will conduct ongoing weekly medication pass observations for four weeks.G. Results of the weekly medication pass observations will be reviewed at QAPI by the DON and/or ADON.H. The DON and/or ADON will continue to conduct annual and PRN medication competencies for all licensed staff.I. The DON/designee are responsible for overall compliance.

Based on observation and interview, the facility failed identify and minimize areas of possible entrapment in resident beds. Specifically: 1.) For Resident #62, out of a total of 19 sampled residents, the facility failed to minimize a gap between the headboard and mattress end of the Resident's bed. 2.) The facility failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 72 resident beds. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the end of the rail and the side edge of the head or foot board) and Zone 7 (Between the head or foot board and the mattress end). Review of guidance from the FDA titled Recommendations for Health Care Providers about Bed Rails, dated 07/09/2018, included: -Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. -Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. 1.) Resident #62 was admitted to the facility in June 2023 with diagnoses including dementia and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/10/24, indicated Resident #62 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS also indicated Resident #62 was able to move from lying to sitting on side of bed with supervision or touching assistance and required partial/moderate assistance to roll left and right in bed. On 10/1/24 at 8:38 A.M., the surveyor observed Resident #62 in bed with a wide gap in Zone 7 (between the head or foot board and the mattress end). On 10/2/24 at 11:19 A.M., the Maintenance Director and the surveyor observed Resident #62's bed. The Maintenance Director had a bed system measuring device, which he said should be used to measure Zone 7 (between the head or foot board and the mattress end) of all bedframes in the building to ensure there were no gaps wide enough for a human head to become entrapped in. The Maintenance Director said the white area on this bed system measuring device represents the average size of a human head. During a measurement using the bed system measuring device, the white area of the device (which represents the average size of a human head), passed freely between the mattress and headboard in Zone 7. The Maintenance Director said the mattress was too small because the gap was wide enough for a human head to become entrapped in, and the gap should have been minimized by inserting a mattress extender but was not. The Maintenance Director said the facility had never measured this bed. Review of facility's binder titled Entrapment Log failed to indicate Resident #62's bed had ever been measured for risk of entrapment. During an interview on 10/2/24 at 12:37 P.M., Nurse #1 said there should never be a gap wide enough to fit a human head between the head or foot board and the mattress end. Nurse #1 said any gap that could fit a human head should be minimized by inserting a mattress extender to prevent entrapment. During an interview on 10/2/24 at 12:40 P.M., the Assistant Director of Nursing (ADON) said there should never be a gap wide enough to fit a human head between the head or foot board and the mattress end. The ADON said any gap that could fit a human head should be minimized by inserting a mattress extender or a bolster to prevent entrapment. During a follow up interview on 10/2/24 at 12:58 P.M., the Maintenance Director said every time a new mattress is placed on an existing bed frame, it should be measured to ensure the mattress fits and does not have any gaps. The Maintenance Director said Resident #62 had a new bed frame delivered a few months ago without a mattress and the facility put a different mattress on the bed frame. The Maintenance Director said the facility never measured to ensure the mattress fit and did not have any gaps but should have. During an interview on 10/2/24 at 1:34 P.M., the Administrator said there should never be a gap wide enough to fit a human head in Zone 7 (between the head or foot board and the mattress end). The Administrator said bed gaps should have been monitored and any gaps should have been minimized but was unable to provide information on how the facility ensured bed gaps were identified and minimized for all beds in the facility. During an interview on 10/2/24 at 2:48 P.M., the Director of Clinical Operations said the facility did not have any policies related to bed inspections, bed safety, or entrapment. The Director of Clinical Operations said bed gaps should have been monitored and any gaps should have been minimized but was unable to provide information on how the facility ensured bed gaps were identified and minimized for all beds in the facility. 2.) Review of facility's binder titled Entrapment Log failed to indicate 72 resident beds (out of 91 total resident beds) had been measured since 2019. During an interview on 10/2/24 at 12:58 P.M., The Maintenance Director said the facility only conducts inspections to measure for areas of possible entrapment on beds with side rails. The Maintenance Director said the facility had 72 beds without side rails that had not been inspected or measured to identify areas of possible entrapment, and these beds were only monitored for function. The Maintenance Director said beds without side rails could have gaps in Zone 7 (between the head or foot board and the mattress end) which could increase the risk for entrapment, but that the facility does not have a process in place to inspect, monitor, or identify possible entrapment for any beds without side rails. During an interview on 10/2/24 at 1:34 P.M., the Administrator said there should never be a gap wide enough to fit a human head in Zone 7 (between the head or foot board and the mattress end). The Administrator said all beds should be monitored to identify areas of possible entrapment but was unable to provide information regarding inspections of any beds that do not have side rails to identify areas of possible entrapment. During an interview on 10/2/24 at 2:48 P.M., the Director of Clinical Operations said the facility does not have any policies related to bed inspections, bed safety, or entrapment. The Director of Clinical Operations said all beds should be monitored to identify areas of possible entrapment but was unable to provide information regarding inspections of any beds that do not have side rails to identify areas of possible entrapment.

Based on observations and staff interviews, the facility failed to follow infection control standards of practice for the cleaning of shared resident equipment. Findings include: Review of the facility policy titled Obtaining a Fingerstick Glucose Level, dated 11/2020, indicated the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. The following equipment and supplies will be necessary when performing this procedure: -Disinfected blood glucose meter (glucometer). Steps in the Procedure: -Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the facility policy titled Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated guidelines for general infection control while caring for residents. Resident-Care Equipment: -When possible, dedicate the use of non-critical resident-care equipment items such as sphygmomanometer (used to take blood pressure) to avoid sharing between residents. -If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. During Medication Observation on the Dolphin Lane unit on 10/2/24 at 7:41 A.M., the surveyor observed breaches in infection control practices when the nurse did not clean the shared resident equipment of the glucometer that was observed to be carried in and out of Residents rooms without cleaning the device. The glucometer is a handheld device that is used in diabetes management to measure the concentration of glucose in the blood. The surveyor observed Nurse #2 entered four different resident's room to take blood sugar measurement using the glucometer and after using it did not clean and/or disinfect between each resident. The surveyor observed the glucometer not being cleaned between resident use or before being returned to the medication cart. During Medication Observation on the Dolphin Lane unit on 10/2/24 at 7:57 A.M., the surveyor observed breaches in infection control practices when Nurse #2 did not clean the shared resident equipment of the portable vital sign device that was observed to be wheeled in out of resident's rooms without cleaning the device. The portable caddy is a device that measures the vital signs of individual residents including a measurement of pulse, blood pressure, temperature, and oxygen saturation rate. The surveyor observed Nurse #2 entered two different residents' rooms to take and record Vital signs using the portable caddy. The surveyor observed the portable device not being cleaned between each resident use and the caddy device did not have the cleaners/disinfectant wipes housed on the bracket shelf. During interview on 10/2/24 at 8:12 A.M., Nurse #2 said she did not disinfect the glucometer or the vital sign caddy, but she should have. During interview on 10/2/24 at 2:57 P.M., The Assistant Director of Nurses, who was also the designated Staff Development Coordinator and the Infection Control Nurse, said shared resident equipment should be disinfected/cleaned before use for another resident.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one Resident (#72) out of a total of 19 sampled residents. Specifically, nursing staff failed to administer insulin per the physicians' sliding scale order. Findings include: Review of the facility's policy titled Administering Medications, dated February 2020, indicated: Medications are administered in a safe, timely manner and as prescribed. Medications are administered in accordance with prescriber orders. Resident #72 was admitted to the facility in April 2024 with diagnoses including diabetes. Review of the Minimum Data Set (MDS) assessment, dated 8/26/24, indicated Resident #72 had severe cognitive impairment as evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #3 required assistance with bathing, dressing and transfers. Review of Resident #72's physician's orders indicated: Novolin R injection solution 100 unit/ML (insulin) Inject as per sliding scale if: 0-200 if FSBS (fasting blood sugars) between 0-60 administer no insulin and follow hypoglycemic protocol and notify MD/RNP: 200 - 250 = 2 251 - 300 = 4 301 - 350 - 6 351 - 400 = 8 401 - 450 = 10 If greater than 450, call on-call provider. Review of Resident #72's September 2024 Medication Administration Record indicated the following: 9/3/24, 12:00 A.M.: BS (blood sugar) 200; no insulin amount documented. Resident #72 should have received 2 units. 9/8/24, 6:00 A.M.: BS 219; no insulin administered. Resident #72 should have received 2 units. 9/8/24, 6:00 P.M.: BS 219; no insulin administered. Resident #72 should have received 2 units. 9/9/24, 6:00 A.M.: No blood sugar level or insulin was documented. 9/13/24, 6:00 A.M.: BS 213; no insulin administered. Resident #72 should have received 2 units. 9/22/24, 8:00 P.M.: BS 213; no insulin administered. Resident #72 should have received 2 units. 9/29/24, 7:30 A.M.: No blood sugar level or insulin was documented. During an interview on 10/2/24 at 2:24 P.M., the Assistant Director of Nursing ADON and the Administrator said that staff should administer medications per the physician's order.

Based on interview and record review the facility failed to obtain routine and 24-hour emergency dental care for one Resident (#11) out of a total sample of 19 residents. Specifically, the facility failed to provide dental services after Resident #11 had voiced that his/her dentures were ill-fitting, and failed to implement the dentist's recommendations for follow-up appointments. Findings include: Review of the facility policy, titled Dental Services, revised November 2017, indicated, but was not limited to, the following: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - All dental services provided are recorded in the resident's medical record. Resident #11 was admitted to the facility in July 2024 with diagnosis including cancer. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #11 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had moderate cognitive impairment. Further review of the MDS indicated the Resident had obvious or likely cavity or broken natural teeth. During an interview on 10/1/24 at 8:01 A.M., Resident #11 said his/her dentures don't fit and that he/she would like to have the dentures fitted as he/she would prefer to use them; the Resident said that this has been the case for a few weeks and that he/she had told staff about his/her ill-fitting dentures. Review of Resident #11's care plans indicated the following care plan initiated on 8/7/24: - Care deficit pertaining to the teeth oral cavity characterized by; altered oral mucous membrane; problems with dentures/ teeth/ gums related to: Broken/carious teeth noted on exam. Further review of the care plan indicated the following intervention initiated on 8/7/24: - Refer to dentist as needed. Review of the dental group note, dated 9/5/24, indicated Resident #11 was seen by a dentist for denture step 5. Further review of the note indicated the Resident received dentures with a recommendation for an annual exam. The following appointments were recommended: - Denture Follow-Up on 9/6/24 - Annual Exam on 9/21/24 Review of Resident #11's medical record failed to indicate the Resident attended the recommended denture follow up or annual exam or that the Resident was seen by a dentist after 9/5/24. Further review of the medical record failed to indicate the Resident was scheduled to see the dentist, or that the Resident had refused to attend any dental appointments. During an interview on 10/2/24 at 10:39 A.M., Certified Nursing Aide (CNA) #6 said that Resident #11 had dentures but he/she does not wear them because the Resident said they don't fit and were too small; CNA #6 said the Resident first mentioned this three weeks ago. During a follow-up interview on 10/2/24 at 1:19 P.M., CNA #6 said that she did not tell the nurse about Resident #11's complaint of his/her dentures being too small and not fitting well because the nurse already knew. During an interview on 10/2/24 at 10:43 A.M., Nurse #1 said the dentist comes every month and that if there was a dental issue the facility would call the dentist and they could come sooner. Nurse #1 said that nurses review the dental group notes/dentist paperwork for recommendations after each visit. Nurse #1 said that Resident #11 recently received dentures but did not wear them and said he was not aware of the Resident's complaints that the dentures were ill-fitting. Nurse #1 said nurses were involved in upcoming dental appointments and would leave notes for upcoming appointments. Nurse #1 said he was unaware of any upcoming dental appointments and that he would have expected the CNA to notify him of the Resident's complaints that the dentures did not fit well and were too small. During an interview on 10/2/24 at 12:48 P.M., the Assistant Director of Nursing (ADON) said refusal for dental appointments would be documented and that she would expect the dentist recommendations for follow-up appointments to be implemented. The ADON said she would expect the CNA to have notified the nurse or tell supervisors about the Resident's complaints about the dentures not fitting well.

Based on observation, record review, and interview the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner. Specifically, the facility failed for Resident #73, to ensure topical medications were not left unattended in the Resident's room. Findings include: Review of the facility's policy: Storage of Medications, dated 4/2018 indicated the facility shall store drugs and biologicals in a safe, secure, and orderly manner. Guidelines: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drugs for external use, shall be clearly marked as such, and shall be stored separately from other medications. 7. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, automatic dispensing systems. Resident #73 was admitted to the facility in November 2023. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 scored an 8 out of fifteen on the Brief Interview for Mental Status (BIMS), indicating he/she had moderately intact cognition. On 10/01/24 at 9:00 A.M., the surveyor observed Resident #73 sitting on the side of his/her bed with the curtain drawn between him/her's roommate. The surveyor observed a bottle labeled Ammonium Lactate 12% lotion with Resident #73's name on it, on the bed side table of Resident #73's roommate. The roommate said that is not mine, referring to the lotion bottle. Review of the medical record for Resident #73 indicated the Resident had not been assessed for self-administering medications. Further review of Resident #73's medical record indicated the following physician's pharmacy order: -Amlactin Daily External Lotion 12% (lactic acid) (Ammonium Lactate) Apply to bilat (bilateral) feet topically every evening shift for dryness, dated 1/31/24. The surveyor made the following observations: -On 10/01/24 at 9:32 A.M., the Ammonium Lactate 12% lotion bottle ordered for Resident #73 was on the bedside table of Resident #73's roommate. -On 10/01/24 at 12:22 A.M., the Ammonium Lactate 12% lotion bottle ordered for Resident #73 was on the bedside table of Resident #73's roommate. -On 10/01/24 at 3:22 PM the Ammonium Lactate 12% lotion bottle ordered for Resident #73 was on the bedside table of Resident #73's roommate. -On 10/02/24 at 8:38 A.M. the Ammonium Lactate 12% lotion bottle ordered for Resident #73 was on the bedside table of Resident #73's roommate. During an interview and observation on 10/2/24 at 8:40 A.M., Nurse #3 said Resident #73 does not self-administer medications and the nursing staff are responsible for administering the Ammonium Lactate 12% lotion for Resident #73. Nurse #3 went to Resident #73's room with the surveyor, removed the Ammonium Lactate 12% lotion from Resident #73's roommates bedside table and said it should not be left in a resident's room and should be locked in the treatment cart. During an interview on 10/2/24 at 12:19 P.M., the Assistant Director of Nursing said all medications including topical medications should be locked in the medication or treatment carts and not left in a resident's room.

Based on observation, record review and interview, the facility failed to provide assistance with meals for two Residents (#21 and #59), out of a total of 19 sampled residents. Findings include: Review of the facility's Care Plans policy dated November 2017 indicated: A comprehensive person-centered care plan will be developed for reach resident. The care plan will include objectives that meet the resident's physical and functional needs for each resident. Review of the facility's Activities of Daily Living (ADLs) policy, dated April 2018 indicated: Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks). 1. Resident #21 was admitted to the facility in September 2022 and has diagnoses that include but are not limited to cerebral infraction, adult failure to thrive, unspecified severe protein-calorie malnutrition, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #21 scored an 11 out of 15 on the Brief Interview for Mental Status indicating Resident #21 had moderately intact cognition and required supervision or touching assistance with eating. Review of Resident #21's Activities of Daily Living (ADL) care plan, dated as initiated 9/30/2022, indicated: Resident has ADL self-care deficit as evidenced by needing assistance with all ADLs (activities of daily living) Interventions: Eating: Independent with set up ->continued supervision, 11/13/22. On 10/1/24 at 10:15 A.M., Resident #21 was observed in bed with a breakfast tray in front of him/her. Resident #21's position was reclined at approximately 45 degrees. Resident was observed chewing with his/her eyes closed. When he/she opened his/her eyes, he/she said he/she was not comfortable. There was not staff in the room or nearby. On 10/1/24 at 12:14 P.M., Resident #21 observed in bed. His/her partially consumed breakfast tray remained in front in front of him/her and his/her eyes were closed. On 10/1/24 at 12:28 P.M., a certified nursing assistant (CNA) entered Resident #21's room with a lunch tray. The CNA set up the tray and exited the room with the breakfast tray. Resident #21 was in his/her room with the privacy curtain pulled, Resident #21 was not able to be seen from the hall. Staff were observed passing lunch trays to residents. On 10/1/24 at 12:34 P.M., Resident #21 was observed with his/her lunch tray untouched and had his/her eyes closed. Resident #21 was positioned at approximately 30-40 degrees and was not upright. On 10/1/24 at 12:38 P.M., Resident #21 had his/her lunch tray which was untouched in front of him/her. Resident #21's eyes were closed. At no time did staff enter the room to supervise or offer any assistance or cueing to eat. On 10/2/24 at 8:53 A.M., Resident #21 was observed with his/her breakfast tray in front of him/her. Resident #21 was not actively eating; the food was untouched and his/her were eyes closed. There were no staff present with Resident #21. At 9:02 A.M., the breakfast tray was no longer present in Resident #21's room. During an interview on 10/2/24 at 12:31 P.M., Nurse #3 said Resident #21 takes his/her time eating. Nurse #3 said we cue him/her from time to time, he/she is not always interested in eating and does need supervision. During an interview on 10/2/24 at 2:04 P.M., CNA #5 said Resident #21 is dependent on care and sometimes refuses and staff need leave and return later. CNA #5 said Resident #21 has not been eating too much and they leave the meal trays. CNA #5 said Resident #21 needs supervision for eating, that staff are not always in the room but check in on him/her to make sure he/she is eating. 36876 2. Resident #59 was admitted to the facility in August 2022 with diagnoses including dementia and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/23/24, indicated Resident #59 had severe cognitive impairment and was dependent on staff for eating. Review of the Activities of Daily Living (ADL) care plan, dated 8/4/22, indicated: Resident has ADL self care deficient [sic]. Interventions: Total assistance with eating, 8/4/22. On 10/1/24 at 8:43 A.M., the surveyor observed Resident #59 seated in his/her room with his/her breakfast plate in front of him/her. Resident #59 was alone and appeared uninterested in the meal. Certified Nurse Assistant (CNA) #4 entered the room and asked Resident #59 if he/she was eating and then left to go to another room saying she would check in later. At approximately 8:50 A.M., the surveyor observed Resident #59 taking small bites of his/her breakfast meal. There was no staff in the room providing assistance. During an interview on 10/1/24 at 12:13 P.M., Family Member #1 said that he was visiting and going to assist Resident #59 with the lunch meal when it arrives. Family Member #1 said he and other family members come in to assist Resident #59 with lunch. Family Member #1 said that staff do not assist Resident #59 with meals. On 10/2/24 at 8:34 A.M., the surveyor observed Resident #59 in bed. His/her breakfast plate was on his/her overbed table and food was splattered across the table. The breakfast tray with his/her drinks and hot cereal was across the room on his/her bureau. Resident #59 was hitting the table repeatedly with his/her hand and not eating. There was no staff in the room providing assistance. During an interview on 10/2/24 at 8:37 A.M., CNA #3 said that Resident #59 is not on her assignment today but she has cared for him/her in the past. CNA #3 said that the Resident does not need assistance with meals. During an interview on 10/2/24 at 8:38 A.M., CNA #2 said that Resident #59 does not need help with his/her meals. On 10/2/24 at 8:40 A.M., the surveyor observed Resident #59 rubbing his/her blanket on the overbed table across the food that had been splattered on the table. Resident #59's blanket was saturated with food and no staff were in the area. On 10/2/24 at 12:22 P.M., the surveyor observed Resident #59 seated alone in his/her room with his/her lunch plate on the overbed table, uncovered and untouched, in front of him/her. Resident #59's lunch tray with beverages was across the room on top of his/her bureau. CNA #3 observed the surveyor standing outside Resident #59's room and then entered the room and sat to assist Resident #59 with his/her meal. During an interview on 10/2/24 at 2:24 P.M., the Assistant Director of Nursing (ADON) and the Administrator said that resident care plans should be followed. The ADON said that the level of assistance Resident #59 needs for meals changes day to day but that staff should be present with him/her during meals for cuing.

Based on observation, record review and interview, the facility failed to 1.) implement the plan of care related to keeping the call light within reach for one Resident (#50), and 2.) failed to develop a care plan related to a history of suicide attempts for one Resident (#11) out of a total of 19 sampled residents. Findings include: Review of the facility policy, titled Care Plans, Comprehensive Person-centered, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. - The resident comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. - Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident conditions change. 1.) Resident #50 was admitted to the facility in December 2021 with diagnoses including weakness and unsteadiness on feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident #50 was moderately impaired as evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #50 required assistance with ambulation and transfers. Review of Resident #50's fall care plan, dated 12/6/21, indicated the following interventions: call light within reach. Review of the facility's policy titled Answering Call Lights, dated April 2018, indicated: When the resident is in bed, provide the call light within easy reach of the resident. On 10/1/24 at 8:08 A.M., and 2:11 P.M., the surveyor observed Resident #50 laying in bed. His/her call light was draped over his/her overbed light hanging behind Resident and out of reach. On 10/2/24 at 7:50 A.M., and 2:19 P.M., the surveyor observed Resident #50 dozing in bed. His/her call light was draped on top of overbed light hanging behind the Resident and out of reach. During an interview on 10/2/24 at 2:24 P.M., the Assistant Director of Nursing (ADON) and the Administrator said that call lights should be placed within the reach of residents at all time. 45763 2.) Resident #11 was admitted to the facility in July 2024 with diagnoses including cancer, manic depression, and schizophrenia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 scored an 11 out of 15 on a Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Review of the behavioral health group note, dated 8/15/24, indicated Resident #11 had a history of suicide attempt and that the Resident had stated he/she had jumped out of a window in a nursing home. Review of Resident #11's care plans failed to indicate that a care plan addressing Resident #11's history of suicide attempts was developed. During an interview on 10/2/24 at 10:47 A.M., Nurse #1 said he was unaware of Resident #11's history of suicide attempts, and that he would expect a care plan to be developed specific to the Resident's history of suicide attempts. Nurse #1 said the interdisciplinary team, including nurses and social workers, review the behavioral health group notes. During an interview on 10/2/24 at 12:22 P.M., the Social Worker (SW) said she would expect nurses and the social workers to review the behavioral health group notes. The SW said she would expect a specific care plan to be developed addressing a resident's history of suicide attempts. During an interview on 10/2/24 at 12:47 P.M., the Assistant Director of Nursing (ADON) said she would expect a resident with a history of suicide attempts to have a care plan developed specifically addressing the history of suicide attempts

Based on observation, policy review, and interview the facility failed to provide a dignified dining experience for two Residents (#1 and #34) out of a total sample of 19 residents. Specifically, the facility failed to ensure that staff members were not standing over Resident #1 and Resident #34 while providing feeding assistance. Findings include: Review of the facility policy titled Resident Rights, revised January 2024, indicated the following: -Employees shall treat all residents with kindness, respect, and dignity. 1.) Resident #1 was admitted to the facility in August 2013 with diagnosis including traumatic brain injury. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was unable to participate in a Brief Interview for Mental Status (BIMS) as the Resident was rarely/never understood. Further review of the MDS indicated Resident #1 had impaired range of motion of upper extremities on both sides, and that the Resident was dependent on staff for eating assistance. On 10/1/24 at 8:20 A.M., the surveyor observed a staff member providing feeding assistance to Resident #1 in his/her room. The Resident was in bed and the staff member was standing over him/her while providing assistance. The bed was not raised, and the staff member and the Resident were not at eye level. On 10/2/24 at 8:19 A.M., the surveyor observed a staff member providing feeding assistance to Resident #1 in his/her room. The Resident was in bed and the staff member was standing over him/her while providing assistance. The bed was not raised, and the staff member and the Resident were not at eye level. During an interview on 10/2/24 at 12:52 A.M., the Assistant Director of Nursing (ADON) said staff should be at eye level with a resident, and not be standing, while providing feeding assistance. 2.) Resident #34 was admitted to the facility in June 2024 with diagnosis including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #34 scored an 8 out of 15 on a Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of the MDS indicated Resident #34 was dependent on staff for partial/moderate feeding assistance. On 10/2/24 at 8:30 A.M., the surveyor observed a staff member providing feeding assistance to Resident #34 in his/her room. The Resident was in bed and the staff member was standing over him/her while providing assistance. The bed was not raised, and the staff member and the Resident were not at eye level. During an interview on 10/2/24 at 12:52 A.M., the Assistant Director of Nursing (ADON) said staff should be at eye level with a resident, and not be standing, while providing feeding assistance.

Based on interview and observation, the facility failed to ensure its laundry room dryer drums, which processed all of the Facility residents' clothing and linens, were free of debris and maintained in safe operating condition, for two of two functioning dryers. Findings include: On 9/28/23 at 8:45 A.M., the surveyor observed three dryers, located in the laundry room. The center of the interior drums of Dryer #1 and Dryer #3 were scorched and covered in debris and what appeared to be melted plastic. During an interview with the Director of Laundry Services on 9/28/23 at 8:46 A.M., he said the facility only had two functioning dryers (Dryer #1 and Dryer #3). The Director of Laundry Services said Dryer #2 was not functioning because it needed replacement parts. The Director of Laundry Services said he also observed the debris in Dryer #1 and Dryer #3. The Director of Laundry Services then attempted to remove some of the debris with a key, but was only able to remove a small amount.

Based on observation and interview the facility failed to adhere to safe practices for food storage, increasing the risk for food borne illness. Specifically, the facility's walk-in refrigerator had ready to eat deli meat and thawed ground meat that was beyond the timeframe in which to serve. Findings include: On 9/26/23 beginning at 7:12 A.M., the surveyor toured the facility kitchen accompanied by the Food Service Director (FSD). The following was observed: Walk-in refrigerator: -One unopened bag of sliced deli roast beef, with a use by or freeze by date of 9/11/23. It was 16 days beyond the date of 9/11/23. -A pan containing ground turkey meat, with a piece of cardboard with a written date of 9/16/23. The date on the ground turkey meat was 11 days after the date of 9/16/23. The FSD said he just pulled the ground turkey from the freezer a few days ago but had the 9/16/23 date on it in error. The ground turkey was soft to touch indicating it was thawed. The FSD said the staff should not use the deli meat or ground turkey even though they were available.

Based on observation, interviews and record review, the facility failed to identify and address a significant weight loss for 1 Resident (#23) and a significant weight gain for 1 Resident (#21) out of a total sample of 22 Residents. Findings include: Review of the facility policy titled Weight measurement revised May 2018 indicated the following: *All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight change (suggested parameters for evaluating significance of unplanned and undesired weight loss are: 5% in 30 days, 7.5% in 90 days and 10% in 180 days) the resident and/or family representative and IDT will be notified, and the plan of care will be revised as appropriate. *The registered dietician will be responsible for determining the desirable weight change. This will be documented on the initial medical nutrition therapy (MNT) assessments and reassessments. * If residents refuse weighing or circumstances prevent weighing the resident, the IDT will document the reason in the residents medical record and care plan. Make attempt to weigh resident at another time. 1.) Resident #23 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, indicating severe cognitive impairment. Further review of the MDS completed in 6/28/22 indicated that Resident #23 requires supervision and set up during meals. During an observation on 9/13/22 at 8:24 A.M., Resident #23 was observed lying in bed. He/she appeared thin and frail. Review of Resident #23's medical record indicated the following weights: 7/14/22-136 lbs (pounds) 7/19/22-135.3 lbs 7/26/22-87 lbs 8/12/22-86.2 lbs 8/16/22-86 lbs 8/23/22-86 lbs 8/23/22-86 lbs 9/08/22-86 lbs *Resident #23 had a significant weight change of 37.76% between 7/14/22 and 8/16/22, a period of 33 days. Further review of the medical record indicated there were no progress notes from the dietitian, interventions or dietary evaluations that addressed Resident #23's weight change. The Dietitian was interviewed on 9/14/22 at 12:10 P.M. and at 1:09 P.M She said a significant weight loss of 37.76% for Resident #23 should have triggered in August 2022. The Dietitian confirmed that the medical record did not have any dietician progress notes, interventions or dietician evaluations on Resident #23. She said the facility expectation is to address any weight changes immediately by re-weighing the Resident to confirm the weight change, address the changes with the interdisciplinary team (IDT), and come up with interventions to address the weight change. 2.) For Resident #21 the facility failed to address a significant weight gain until it was identified by the surveyor. Resident #21 was admitted to the facility in March 2022, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #21 scored a 15 out of a possible 15 indicating intact cognition. The MDS further indicated Resident #21 had no behaviors, and required extensive physical assistance with Activities of Daily Living (ADLs). During a record review on 9/13/22 at 10:12 A.M., the following was indicated: * On 9/1/2022, Resident #21 weighed 151.0 lbs and on 9/08/2022, Resident #21 weighed 160.2, indicating a 6.09 % weight gain in one week. * The most recent nutrition assessment was completed 6/27/22, and indicated Resident #21's goals were to maintain a weight free from significant changes. Resident #21 may benefit from slow gradual and controlled weight gain. * The most recent dietitian's progress note was dated 7/12/22. The record failed to indicate: * Resident #21 was re-weighed following the weight obtained on 9/8/22, indicating a 6.09% weight gain in one week, or that Resident #21 had refused a reweigh. * The physician or dietitian were aware of the weight gain. * Any clinical progress notes, or interventions related to the weight gain. During an interview with the Dietitian on 9/14/22 at 11:15 A.M., she said that she was not aware that Resident #21 had a significant weight gain this month. The Dietitian calculated the weights and verified the 6.09 % weight gain. She said normally if a weight gain is noted, the staff leave her a note to see the patient, but in this case that did not happened. She re-checked her email which indicated that no one had alerted her to the weight gain. During an observation on 9/14/22 at 12:08 P.M., the surveyor observed the Dietitian report to Nurse #3 that she just evaluated Resident #21 and that she was recommending to discontinue the tube feed based on the significant weight gain. During an interview with Nurse #3 on 9/14/22 at 12:11 P.M., she said that if it is noted that a resident has had a significant weight loss or gain the process is to: * reweigh the resident to confirm the accuracy of the weight change. * If a weight change of significance is noted the nurse should notify the physician and dietitian and document it in a progress note, but in this case that did not happen.

Based on records reviewed and interviews, for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free from medication errors and received medications as prescribed by his/her Physician. At approximately 5:15 A.M. on 12/9/16, Resident #1 complained of numbness in his/her throat, arms, and legs, was vomiting, and said the wrong medications were administered to him/her the previous evening. Resident #1 was transferred to the Emergency Department where his/her urine toxicology results revealed the presence of [MEDICATION NAME] (a narcotic used for treating pain and/or drug addiction), which was not a medication prescribed for Resident #1 by his/her Physician and Resident #1 was treated with intravenous fluids for [DIAGNOSES REDACTED]. Findings include: Resident #1's Admission Minimum Data Set (MDS) indicated Resident #1 was admitted to the Facility for short term rehabilitation on 11/29/16 and was discharged home with services on 12/12/16. He/she was alert, oriented, and cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. A Nurse's Progress Note, dated 12/9/16 and timed at 6:09 A.M., indicated that Resident #1 vomited twice, was diaphoretic (sweating), complained of numbness in his/her throat, arms, and legs, and Resident #1 said that the reaction was because he/she had been given too much medication the previous night. The Surveyor interviewed Nurse #1 on 3/17/17 at 4:05 P.M. Nurse #1 said during her 11 P.M. to 7 A.M. shift on 12/9/16, Resident #1 woke up early in the morning and vomited, said he/she was light headed, and he/she was given too much medicine the night before. Nurse #1 said she called to notify Resident #1's Physician who gave an order to transfer Resident #1 to the Emergency Department. The Surveyor interviewed the Assistant Director of Nursing (ADON) on 3/21/17 at 11:22 A.M. The ADON said she spoke with Resident #1 prior to his/her transfer to the Hospital. The ADON said Resident #1 told her that around dinner time the night before, when Nurse #2 gave him/her some pills, Resident #1 counted the pills and told Nurse #2 they weren't his/her pills, but Nurse #2 told Resident #1 to take them because they were his/her pills, or words to that effect. The ADON said, shortly after Resident #1 left the Facility, the Unit Manager informed her that Resident #1's Roommate (Resident #2) had an order for [REDACTED]. The Surveyor interviewed Nurse #2 on 3/21/17 at 4:12 P.M. Nurse #2 said that on 12/8/16 while he was administering medications, although he did not recall Resident #1's concerns about receiving medications that were not his/her, he did recall that he was distracted and frequently interrupted while he was trying to administer medications to residents. An Incident Report submitted by the Facility to the Department of Public Health on 12/16/16 indicated that, after an internal investigation, the Facility concluded that a medication administration error had occurred and that Resident #1 was administered Resident #2's [MEDICATION NAME] on 12/8/16 in error. Resident #2's monthly physician's orders [REDACTED].#2 was to receive four 10mg tablets of [MEDICATION NAME] once per day for which the Facility scheduled to be given daily at 5:00 P.M. Resident #1's monthly physician's orders [REDACTED].>Resident #1's After Visit Summary from the Hospital, dated 12/9/16, indicated that Resident #1's urine toxicology results were positive for [MEDICATION NAME] and Resident #1 was treated with intravenous fluids for [DIAGNOSES REDACTED].

Based on interviews, records reviewed, and observations, for 2 out of 7 sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision to prevent elopement. On 1/17/17, Resident #1 eloped, and was found dead the following morning by local police. In addition, Resident #2 eloped from the Facility, and was noticed outside, on the sidewalk. In addition the Facility failed to: - accurately assess 2 Resident out of 7 sampled residents (Resident #1 and Resident #5) for elopement risk. Resident #1 was admitted in October 2016, in December ambulation had improved and the Facility failed to ensure Resident #1 was re-assessed for elopement risk. Resident #5 was documented as physically unable to exit the building, however was observed by Surveyor #1 and Surveyor #2 exiting the Facility on his/her own, staff said he/she would exit the Facility frequently, however no assessment or plan of care was in place to address Resident #5's safety when outside of the Facility. -relay information to staff caring for residents at risk for elopement; - to ensure no residents had left the Facility or perform a head count of residents on the unit when the door alarm (which sounded when a person had exited)sounded at the front main entrance of the Facility; - to maintain up to date accurate information regarding residents who had been identified at risk for elopement for the staff who supervised the front door from 8:00 A.M. to 6:00 P.M. The Facility relied on the use of a door alarm after 6:00 P.M. that alerted staff whenever the front main door was opened. However, staff who routinely worked on the unit said the alarm was not audible in all areas of the unit, such as residents' rooms. Staff said that when the alarms sounded and they shut the alarm off, they did not check to see if a resident exited the facility through the front door and did not perform a head count to ensure all residents at risk for elopement were present. Findings include: 1: Facility Policy titled Elopement Guideline dated 01/12/2017, indicated the Facility will identify environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have exit seeking behavior, and will implement interventions to minimize these risks and hazards as appropriate, and all residents at risk for elopement would be assessed quarterly and as needed. Facility Policy titled Transfer of Resident Within the Facility, dated 5/3/16, indicated Nursing would conduct a thorough hand off communication regarding care of the resident. Resident #1 was admitted to the Facility in October, 2016, and his/her [DIAGNOSES REDACTED]. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 10/13/16, indicated Resident #1 was not physically able to leave the building on his/her own, was cognitively impaired and disoriented at all times, and had impaired decision making skills. A Minimum Data Set (MDS) assessment, dated 10/20/16, indicated; Resident #1 was severely cognitively impaired, and required extensive assistance from staff for ambulation. Resident #1's health status improved with Physical Therapy over the course of the next few months. A Physical Therapy Progress Note, dated 12/1/16, indicated Resident #1's mobility and ambulation status had improved, and he/she was able to walk 400ft with minimal staff assistance at the time of discharge from skilled services. A Discharge Planning Meeting minutes note, dated, 1/11/17, indicated Resident #1 had made tremendous progress physically, but not in cognitive status, and would be transferred to long term care. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/27/16, indicated; Resident #1 had a memory problem. The risk for elopement section of the assessment was not completed. There was not an updated risk for elopement assessment completed to reflect Resident #1's improved mobility status, which would have changed the outcome of his/her elopement risk assessment. (This was inconsistent with Facility Policy titled Elopement Guideline). An MDS assessment, dated 12/8/16, indicated Resident #1 was severely cognitively impaired, and required minimal assistance from staff for ambulation. A Plan of Care, dated, 12/14/16, indicated Resident #1 was at risk for falls, and a pressure sensitive alarm (a device that sounds when a resident has moved) was ordered for Resident #1's bed to prevent falls. A Weekly Care Management Meeting Note, dated 1/10/17, indicated Resident #1 could transfer him/her self independently, was cognitively impaired, and had poor safety awareness. A Progress Note, dated 1/17/17, timed 2:27 P.M., indicated Resident #1 was transferred to the B Wing from another unit within the Facility. A Nurse Progress Note, dated 1/18/17, timed 12:06 A.M., indicated staff were not able to locate Resident #1, and a report had been filed with the local Police Department. The note did not indicate when Resident #1 was first noticed missing. Surveyor #1 and Surveyor #2 interviewed the Business Office Manager at 11:59 A.M. on 1/19/17. The Business Office Manager said she was stationed at the front desk near the front main door of the Facility Monday through Friday from 8:00 A.M., to 6:00 P.M., while performing her own office tasks such as answering the phone and other work, and there would be a staff person scheduled to sit at the front desk on Saturdays and Sundays. The Business Office Manager said after 6:00 P.M., no one was stationed at the front main door, and the front door alarm would be turned on to alert staff when someone opened the door. Surveyor #1 and Surveyor #2 interviewed Nurse #1 at 10:51 A.M. on 01/20/17. Nurse #1 said the alarm at the front door will sound when opened after 6:00P.M., however the alarm was hard to hear from the unit, and is unable to be heard from the resident rooms. Nurse #1 said during the 3:00 P.M. to 11:00 P.M. shift on 1/17/17, the front lobby was very busy, she had to turn off the front door alarm several times, and said she did not always check to see who had exited the building through the front door. Surveyor #1 interviewed Nurse #2 at 3:11 P.M., on 1/23/17. Nurse #2 said she worked during the 7:00 A.M. to 3:00 P.M. shift on the B Wing of the Facility on 1/17/17. Nurse #2 said Resident #1's room was changed from another unit within the Facility around 1:45 P.M., to the B Wing. Nurse #2 said she did not receive a Nurse to Nurse report when Resident #1 was moved to the B Wing (this was inconsistent with Facility policy titled Transfer of Resident Within the Facility). Nurse #2 said Resident #1 did not have a pressure sensitive alarm in place, was able to ambulate on his/her own, and had short term memory loss. Nurse #2 said Resident #1 had not been identified as at risk for elopement to her. Nurse #1 said she received shift change report from Nurse #2 at 3:00 P.M. on 1/17/17, and she was told Resident #1 had been moved to B Wing from another unit within the Facility earlier that day. Nurse #1 said she was told Resident #1 was forgetful, was known to wander, had short term memory loss, would forget where his/her room was, was able to ambulate on his/her own, could use the bathroom independently, and did not have a pressure sensitive alarm in place, (this was inconsistent with Resident #1's care plan). Nurse #1 said she did not give report to the Certified Nurses' Aides (CNAs) on the unit that shift. Nurse #1 said she last saw Resident #1, in bed, just after 7:00 P.M., when she gave him/her medications. Nurse #1 said around 7:45 P.M., CNA #1 told her Resident #1 was not in his/her room, a Facility-wide search was initiated, staff were not able to locate Resident #1, and the local Police were notified. Surveyor #1 and Surveyor #2 interviewed CNA #1 at 3:41 P.M., on 1/19/17. CNA #1 said the alarm for the front main door of the Facility was hard to hear from the unit, and she could not hear the alarm when working in a resident room. CNA #1 said she did not receive a report from Nurse #1 during the 3:00 P.M. to 11:00 P.M. shift on 1/17/17, and said she was not familiar with Resident #1 or his/her care needs, and she did not know if he/she was at risk for elopement. CNA #1 said Resident #1 did not have a bed alarm in place, and he/she was using the bathroom and ambulating in his/her room independently (this was inconsistent with Resident #1's care plan). CNA #1 said she last saw Resident #1 in bed, around 7:00 P.M. and around 7:45 P.M., she noticed Resident #1 was not in his/her room, she notified Nurse #1, and a search of the Facility was initiated. A Police Report, dated 1/17/17 indicated, the Facility called to report Resident #1 missing at 8:08 P.M., and reported he/she had last been seen by staff between 7:00 P.M., and 7:30 P.M. on 1/17/17. A Police Report from a neighboring city, dated 1/18/17, indicated Resident #1 was found, unresponsive at approximately 6:23 A.M., outside, behind a business building. Resident #1 was pronounced dead at the scene by emergency first responders, at 6:30 A.M. on 1/18/17. 2: Resident #2 was admitted to the Facility in December, 2016, and his/her [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#2 was to have a wander alert bracelet (a device which triggers an alarm to alert staff when a person is near an exit) to prevent elopement. A Nurse Progress Note, dated 1/1/17, timed 11:15 A.M. indicated, Resident #2 was found outside the Facility, when another Resident alerted staff that he/she had walked out the front door of the Facility. Surveyor #1 interviewed Nurse #3 at 8:46 A.M., on 1/25/17. Nurse #3 said another resident alerted staff that Resident #2 was outside, sometime late in the morning on 1/1/17. Nurse #3 said Resident #2 had a wander alert bracelet in place, which was functioning, and the alarm at the door was sounding. Nurse #3 said Resident #2 was at the sidewalk in front of the Facility, which is on a main road when she and CNA #2 caught up with him/her and were able to redirect him/her back into the Facility. Nurse #3 said she could not recall if there was a staff member at the front desk that day. Surveyor #1 interviewed CNA #2 at 9:57 A.M., on 1/25/17. CNA #2 said sometime late in the morning on 1/1/17, another resident alerted her that Resident #2 was outside. CNA #2 said she and Nurse #3 ran outside through the front main door of the Facility, and caught up to Resident #2, outside the Facility, near a main road. CNA #2 could not recall if she heard the wander alert alarm sounding at the time. On 1/19/17, The Wander Prevention Watch List, dated 1/3/17, located in the front of the Elopement Book indicated there were 12 residents at risk for elopement. This list was not accurate because Resident #2, who had been discharged from the Facility on 1/11/17, was listed as at risk for elopement. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses(DON) at 3:20P.M. on 1/19/17. DON said she was responsible for keeping the elopement book up to date, it was reviewed weekly, and had been reviewed with no changes needed on the morning of 1/19/17 (this was inconsistent with the fact that Resident #2 had been discharged , and was still on the Wander Prevention Watch List). 3. The Facility failed to ensure resident safety by failing to secure oxygen tanks, located in an unlocked closet, in a back room which were accessible by 2 unlocked doors and were adjacent to areas frequented by the resident population (the main dining room and a hallway on a residential unit). Throughout the survey on 1/19/17 and 1/23/17, it was observed, the door to the oxygen closet, which contained 2 large unsecured portable oxygen tanks, 4 small portable oxygen tanks on a shelf and unsecured, one large green refillable oxygen tank, and several small green refillable oxygen tanks was unlocked, and the back room where the oxygen room was located was accessible through unlocked doors adjacent to the main dining room as well as a hallway on a resident unit at the following times: -At 12:10 P.M. on 1/19/17, by Surveyor #1 and Surveyor #2. At that time, Surveyor #2 informed the Administrator that the room containing oxygen tanks should be locked, for resident safety. -At 10:53 A.M. on 1/23/17, by Surveyor #1, Surveyor #3, and Surveyor #4. -At 5:48 P.M. on 1/23/17, by Surveyor #1 and Surveyor #2. At that time, the Assistant Director of Nurses was present, and the surveyors informed her that the room containing oxygen tanks should be locked, for resident safety.

Based on interviews and records reviewed, for 1 out of 3 sampled residents, (Resident #1), the Facility failed to maintain a secure environment and provide adequate supervision, which led to Resident #1, who was cognitively impaired, to elope from the building, and walk outside along the streets after sunset, with temperatures averaging 32 degrees F, causing Resident #1 to suffer abrasions on his/her knee, pain in both hips,when found 90 minutes later, Resident #1's body temperature was 96.2 degrees F, and fatigue. Findings include: A local weather report from weather.com indicated, temperatures on 11/21/16 were between 30-37 degrees Fahrenheit. Facility policy titled Elopement Guideline, dated 10/2015, indicated, the (Facility) will identify such environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have exit seeking behavior. The (Facility) will implement interventions to minimize these risks and hazards as appropriate, and upon admission, each resident is reviewed to establish elopement risk using the Clinical Health Status form, and the Family may be interviewed for resident's previous history of elopement and responses recorded in the medical record. Resident #1's [DIAGNOSES REDACTED]. After the incident of elopement, his/her spouse revealed he/she had a history of [REDACTED]. A Minimum Data Set (MDS) evaluation, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation. A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied. Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times. A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and he/she was found at or around 8:35 P.M., by a staff, approximately 2 miles from the Facility, had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, Nurse Practitioner #1 was notified, and orders for X-rays of the sites to rule out fractures was obtained. A Police Report, dated 11/21/16, indicated, Resident #1 was reported missing at 7:52 P.M., (approximately 52 minutes after Resident #1 was first noticed missing), on 11/21/16, and was located 30 minutes later by Facility staff. Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said Resident #1 was known to wander, was exit seeking, and a wanderguard bracelet was in place. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., and a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called Resident #1's spouse, then the local Police Department about 15 minutes after first noticing Resident #1 was missing. This was inconsistent with the Police report. Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 90 minutes after he/she was missing), walking along a main road, and was returned to the Facility. Nurse #1 said Resident #1 was shivering, and his/her body temperature was assessed at 96.something or words to that effect, and he/she had sustained abrasions to his/her right knee, however, due to cognitive loss, was unable to recall if he/she had fallen. Nurse #1 said he updated the local Police that Resident #1 had been found. Nurse #1 said Resident #1 had his/her wanderguard alarm bracelet in place upon return to the Facility, and the wanderguard system and Resident #1's wanderguard bracelet were functioning. CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching for Resident #1. CNA #1 said staff on the other units were also searching for Resident #1, and when he/she could not be found, Nurse #1 called the local Police Department, approximately 45 minutes to 1 hour after Resident #1 was first noticed missing. CNA #1 said, after the Police became involved, Facility staff stopped searching, and continued to provide care for the other residents. CNA #1 said he later took his 30 minute break, and was driving his car, and noticed Resident #1 walking and stumbling along a main road, approximately 2 miles from the Facility. CNA #1 said Resident #1 was wearing a lined plaid coat, no hat, gloves, or mittens, was shivering, and said he/she was cold. The Director of Nurses was interviewed at 9:32 A.M., on 12/12/16. The Director of Nurses said there was an internal investigation conducted to determine the root cause of Resident #1's elopement, and it was determined Resideent #1 might have followed a visitor or an ambulance crew out the door, however there were no conclusive findings. The Director of Nurses said only staff of the Facility are allowed to know the code to disarm the alarm at the door, and staff are to accompany anyone exiting the Facility after 6:00 P.M.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), the Facility failed to ensure that Resident #4, who was cognitively impaired and required 1:1 supervision due to aggressive behaviors and periods of agitation, understood and consented to being hidden in a basement level office, on 1/25/17, during a Mock Elopement Drill. Approximately 2 hours later, Resident #4 was transferred and admitted to the Hospital under a Section 12 order (emergency involuntary psychiatric hospitalization ) for physical aggression and inability to understand his/her situation. Findings Include: The Facility's Policy, titled Residents Rights and dated 11/28/16, indicated the Facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to, the right to make choices about aspects of his or her life in the Facility. An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated Resident #4 had a [DIAGNOSES REDACTED]. A Nurse's Progress note, dated 1/23/17 and timed at 12:01 A.M., indicated Resident #4 was agitated with periods of restlessness and aggressive behaviors, and was placed on direct 1 to 1 staff observation. A Nurse Practitioner's Progress Note, dated 1/25/17, indicated that prior to Resident #4's admission to the Facility, he/she had worsening paranoia with agitation. Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1:1 observation. CNA #1 said at that time Resident #4 was asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4's room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility, because a Mock Elopement Drill was about to take place. CNA #1 said, I woke Resident #4 up, got him/her out of bed, took him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later. CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with the Facility's Policy titled Resident's Rights. Surveyor #1 and Surveyor #2 interviewed the Administrator on 1/31/17 at 1:30 P.M. The Administrator said that he was standing at the Nurse's Station during the Mock Elopement Drill and was startled, or words to that effect, when someone opened the office door directly accross from the Nurse's Station and he saw Resident #4. The Administrator said he did not recall a decision being made by the Interdisciplanary Team members to hide Resident #4 in the office during the Mock Code Elopement Drill. The Administrator said consent was not obtained from Resident #4's Health Care Agent for Resident #4 to be taken from his/her unit and hidden in the Facility during the Mock Elopement Drill. This was not consistent with the Facility Policy titled Resident's Rights. An Elopement/Missing Person Mock Drill form dated 1/25/17 and timed at 1:40 P.M. indicated Resident #4 was located within the Facility at 1:44 P.M. An Application For Authorization of Temporary Involuntary hospitalization (Section 12) dated 1/25/17 and timed at 1:46 P.M., indicated that Resident #4 was physically aggressive and unable to understand his/her situation. The Emergency Department Record, dated 1/25/17 and timed at 3:46 P.M., indicated that Resident #4 was sent from the Facility on a Section 12 order for behavior disturbances, combativeness, and worsening agitation, and that Resident #4 was unsure why he/she was there. Resident #4 was admitted to a Psychiatric Unit for further evaluation.

Based on interviews and records reviewed, for 1 out of 3 sampled residents (Resident #1), the Facility failed to notify the Physician of an acute change in condition, when Resident #1, who was cognitively impaired, eloped from the Facility, and was found approximately 2 miles from the Facility, outside exposed to temperatures between 30 to 37 degrees Fahrenheit, for approximately 1 hour and 30 minutes, and when found, had sustained abrasions to his/her right knee, had pain in both hips, a body temperature of 96.2 degrees Fahrenheit (F), and fatigue. Nurse Practitioner #1 was on call, was not notified until approximately 90 minutes after Resident #1 was found and returned to the Facility, and was not notified of Resident #1's body temperature of 96.2 degrees F. Findings include: A Facility policy titled: Notification of Changes in Resident Health Status dated 10/20/16, indicated, the Facility will immediately consult the resident's physician, nurse practitioner, or physician's assistant when there is an accident or acute significant change in the resident's status which results in injury and has the potential for requiring physician intervention. A local weather report from weather.com indicated, temperatures on 11/21/16 were between 30-37 degrees Fahrenheit. Resident #1's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) evaluation, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation. A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied. Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times. A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and Resident #1's spouse was notified as well as the local Police Department, and he/she was found at or around 8:35 P.M., by a staff, approximately 2 miles from the Facility. The note indicated that when found, Resident #1 had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, and Nurse Practitioner #1 was notified, who ordered X-rays of the sites to rule out fractures. A Police Report, dated 11/21/16, indicated, Resident #1 was reported missing at 7:52 P.M., (approximately 52 minutes after Resident #1 was first noticed missing), and was located by Facility staff, 30 minutes after the police were notified. Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., on 11/21/16, and a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called Resident #1's spouse, then the local Police Department about 15 minutes after first noticing Resident #1 was missing, (this was inconsistent with the Police report). Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 1 hour and 30 minutes after he/she was missing), walking along a main road, and was returned to the Facility. Nurse #1 said Resident #1 was shivering, and his/her body temperature was assessed at 96.something or words to that effect, and he/she had sustained abrasions to his/her right knee, however, due to cognitive loss, was unable to recall if he/she had fallen. Nurse #1 said he updated the local Police that Resident #1 had been found. Nurse #1 said he notified Nurse Practitioner #1 regarding Resident #1's elopement and assessment upon return to the Facility, and an order for [REDACTED].#1 said he did not notify the Medical Director of Resident #1's elopement. CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching the Facility for Resident #1. CNA #1 said staff on the other units were also searching for Resident #1, and when he/she could not be found, Nurse #1 called the local Police Department, approximately 45 minutes to 1 hour after Resident #1 was first noticed missing. CNA #1 said, after the Police became involved, Facility staff stopped searching, and continued to provide care for the other residents. CNA #1 said he later took his 30 minute break, and was driving his car, and noticed Resident #1 walking and stumbling along a main road, approximately 2 miles from the Facility. CNA #1 said Resident #1 was wearing a lined plaid coat, no hat, gloves, or mittens, was shivering, and said he/she was cold. Nurse Practitioner #1 was interviewed at 2:12 P.M., on 12/13/16, and again at 8:30 A.M., on 12/14/16. Nurse Practitioner #1 said she was notified, at 10:08 P.M., on 11/21/16, that Resident #1 had eloped from the Facility and was found around 8:30 P.M., had sustained abrasions on his/her right knee, and was complaining of pain in both hips. Nurse Practitioner #1 said she was not notified that Resident #1 had been missing from the Facility for 1 hour and 30 minutes before he/she was found, or that his/her body temperature was measured at 96.2 degrees Fahrenheit. This was inconsistent with Facility policy and Nurse #1's statement. Nurse Practitioner #1 said she was unaware of the weather conditions that night, and said I make and receive these calls from inside my condo, or words to that effect. Nurse Practitioner #1 said she told Nurse #1 to refer to the Facility's policy and/or the Medical Director's discretion to determine whether to send Resident #1 to the emergency room . The Medical Director was interviewed at 11:05 A.M., on 12/16/16. The Medical Director said he could not recall being notified of Resident #1's elopement on 11/21/16.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), the Facility failed to maintain an environment that met Resident #4's behavioral health needs. On 1/25/17, Resident #4, who was cognitively impaired and on 1:1 observation for increased anxiety and aggressiveness, was taken from his/her room on the ground level of the Facility, into an office on the basement level of the Facility, and hidden behind closed doors during a Mock Elopement Drill. Approximately 2 minutes after the drill was over, staff completed an application for Section 12 transfer (emergency involuntary psychiatric hospitalization ) and approximately 2 hours later Resident #4 was transferred to the Hospital for Psychiatric evaluation, and was admitted and treated for [REDACTED]. Findings Include: An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated that Resident #4 had a [DIAGNOSES REDACTED]. A Behavioral Care Plan, dated 11/14/16, indicated Resident #4 had aggressive behaviors, and staff were to avoid situations that were upsetting to Resident #4. A Nurse Practitioner's Progress Note, dated 1/25/17, indicated that prior to Resident #4's admission to the Facility, he/she experienced worsening paranoia with agitation and Resident #4 had been placed on 1 to 1 observation for aggressive behaviors. Surveyor #3 interviewed the Director of Social Services 2/2/17 at 4:03 P.M. The Director of Social Services said Resident #4's behavior was unstable and he/she was unable to understand his/her environment which made him/her aggressive. Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1 to 1 observation. CNA #1 said at that time Resident #4 was asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4's room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility, because a Mock Elopement Drill was about to take place. CNA #1 said she woke Resident #4 up, got him/her out of bed, took him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later. CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with Resident #4's Behavior Care Plan. Surveyor #1 and Surveyor #2 interviewed the Staff Development Coordinator on 1/31/17 at 2:22 P.M. The Staff Development Coordinator said that, during an Interdisciplinary Team (IDT) meeting, unsure of exact date or time, a decision was made by the IDT members to use Resident #4 during the Mock Elopement Drill, and hide him/her in the Staff Developer's office located in the basement level of the Facility, because they wanted staff to take the drill seriously and because Resident #4 moves fast and looks like a visitor, or words to that effect. The Staff Development Coordinator said she did not recall asking CNA #1 to take Resident #4 downstairs to the office. This was not consistent with statement made by CNA #1. An Elopement/Missing Person Mock Drill Form dated 1/25/17 indicated Resident #4 was located within the Facility at 1:44 P.M. Surveyor #1 and Surveyor #2 interviewed the Administrator on 1/31/17 at 1:30 P.M. The Administrator said that he was standing at the Nurse's Station during the Mock Elopement Drill and he was startled, or words to that effect, to see Resident #4 in the office directly accross from the Nurse's Station when a Staff member opened the door. The Administrator said he did not think the Facility was supposed to use residents for Mock Drills and he asked a staff member to take Resident #4 back upstairs to his/her room. An Application For Authorization of Temporary Involuntary hospitalization (Section 12) was dated 1/25/17 and timed at 1:46 P.M., 2 minutes after the Mock Elopement Drill ended, documentation indicated that Resident #4 was physically aggressive and unable to understand his/her situation. Surveyor #3 interviewed the Nurse Practitioner on 2/2/17. The Nurse Practitioner said she saw Resident #4 on the morning of 1/25/17 and at that time Resident #4 was not agitated. The Nurse Practitioner said the Facility did not notify her as to why a Section 12 Application was completed for Resident #4 at 1:46 P.M. on 1/25/17. The Nurse Practitioner said she did not give an order to transfer Resident #4 to the hospital on [DATE] and it wasn't until she visited the Facility on 1/26/17, that she learned Resident #4 had been transferred for a Psychiatric Evaluation, at which time she signed the Telephone Order. The Emergency Department Record, dated 1/25/17 and timed at 3:46 P.M., indicated that Resident #4 was sent from the Facility on a Section 12 order for behavioral disturbances, combativeness, and worsening agitation, and Resident #4 was unsure why he/she was there. The Physician History and Physical, dated 1/26/17, indicated that Resident #4 was having increased episodes of agitation, combativeness, difficulty following directions, and had increased irritability late in the afternoon into the evening. .

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), who was cognitively impaired and required 1 to 1 supervision due to periods of aggressive behaviors and agitation, that during a Mock Elopement Drill conducted on 1/25/17, the Facility failed to ensure: - staff obtained consent prior to hiding Resident #4 in a basement office. - that prior to completing a Section 12 (emergency involuntary psychiatric hospitalization order) application, that staff notified Resident #1's Physician and or Nurse Practitioner, and failed to ensure a thorough clinical assessment was completed with supporting documentation to support the decision to transfer Resident #4 to the hospital, approximately 2 hours after the Mock Elopement Drill was completed. - a valid Physician order [REDACTED]. to the Hospital under a Section 12 order. - Resident #4 was admitted to the Hospital for in-patient treatment for [REDACTED]. Findings include: 1. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. According to 244 CMR 9.03 Standards of Conduct for Nurses (44) Documentation: A nurse licensed by the Board shall make complete, accurate, and legible entries in all records required by federal and state laws and regulations and accepted standards of nursing practice. On all documentation requiring a nurse's signature, the nurse shall sign his his or her name as it appears on his or her license. A House Bill 4681, an Act to Improve Emergency Access to Mental Health Services (Section 12 Law), indicated as of November 8, 2010, LICSWs in the Commonwealth of Massachusetts will be authorized to sign a Section 12(a), known as a pink paper. Part of the procedure indicates that documentation supporting the bases for the decision to seek a commitment is an integral part of the process. 2. The Facility Policy, titled Residents Rights, dated 11/28/16, indicated the Facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to, the right to make choices about aspects of his or her life in the Facility. The Facility's Policy, titled Content of the Medical Record Policy, dated 11/28/16, indicated the Nursing Progress Note documentation should include resident's changes in behavior and documentation of resident's visits to the hospital. The Facility's Policy, titled Physician Telephone Orders, dated 1/29/14, indicated the Licensed Nurse must document all Physician's telephone orders including the date the order was obtained, time the order was obtained, the content of the physician's orders [REDACTED]. 3. An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated Resident #4 had a [DIAGNOSES REDACTED]. A Nurse's Progress note, dated 1/23/17 and timed at 12:01 A.M., indicated Resident #4 was agitated with periods of restlessness and aggressive behaviors, and was placed on direct 1 to 1 staff observation. Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1:1 observation. CNA #1 said at that time Resident #4 was in asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4's room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility because a Mock Elopement Drill was about to take place. CNA #1 said she woke Resident #4 up, took him/her out of bed, brought him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later. CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with the Facility Policy titled Resident's Rights. An Elopement/Missing Person Mock Drill Form, dated 1/25/17, indicated Resident #4 was located within the Facility at 1:44 P.M. An Application For Authorization of Temporary Involuntary hospitalization (Section 12), dated 1/25/17 and timed at 1:46 P.M., 2 minutes after the Mock Elopement Drill ended, indicated that Resident #4 was physically aggressive and unable to understand his/her situation. There was no documentation in Nurse Progress Notes or Behavior Sheets, on 1/25/17, which indicated a thorough clinical assessment was performed on Resident #4 prior to completion of the Section 12 order, or a reason why Resident #4 was transferred out of the Facility on a Section 12 order for a psychiatric evaluation. Surveyor # 3 interviewed the Director of Social Services on 2/2/17 at 4:03 P.M. The Director of Social Services said that although she did complete a Section 12 Application for Resident #4 on 1/25/17, she did not speak to Resident #1's Physician or Nurse Practitioner regarding this Application. The Director of Social Services said Resident #4 had a history of [REDACTED].#4 would require a psychiatric evaluation, or words to that effect, and to the best of her recollection Resident #4 was fine, or words to that effect, on 1/25/17. A Physician Telephone Order, dated 1/25/17 timed at 2:35 P.M. and documented as signed by Nurse #1, indicated Resident #4 was to be transferred to the emergency room for evaluation. Surveyor #3 interviewed Nurse #1 on 2/2/17 at 2:21 P.M. Nurse #1 said that although she did write the Physician's telephone order on 1/25/17 to transfer Resident #4 to the Hospital for a psychiatric evaluation, she never called to obtain the order from Resident #4's Physician or Nurse Practitioner because the Director of Social Services told her she wanted to transfer Resident #4 to the Hospital quickly and told her to Just write the order herself, or words to that effect. This was not consistent with the Facility Policy titled, Physician Telephone Orders. Surveyor # 3 interviewed the Director of Social Services on 2/2/17 at 4:03 P.M. The Director of Social Services said she had no recollection of telling Nurse #1 to write a physician's orders [REDACTED].#4 to the Hospital for Psychiatric Evaluation on 1/25/17. An emergency room Admission report, dated 1/25/17, indicated Resident #4 arrived at Hospital at 3:46 P.M. on a Section 12 for behavioral disturbance and worsening agitation, he/she was unsure why he/she was there, and Resident #4 was admitted to a Psychiatric Unit with a [DIAGNOSES REDACTED]. Surveyor #3 interviewed the Nurse Practitioner on 2/2/17. The Nurse Practitioner said she saw Resident #4 on the morning of 1/25/17 and at the time Resident #4 was not agitated. The Nurse Practitioner said the Facility did not notify her as to why a Section 12 Application was completed for Resident #4 at 1:46 P.M. on 1/25/17. The Nurse Practitioner said she did not give an order to transfer Resident #4 to the hospital on [DATE] and it wasn't until she visited the Facility on 1/26/17, that she learned Resident #4 had been transferred for a Psychiatric Evaluation and she signed the Telephone Order at that time.

Based on interviews and records reviewed, the Facility failed to develop and implement an effective emergency preparedness plan for resident elopement for 1 out of 3 sampled residents (Resident #1), and 5 non sampled residents, when Resident #1, who had cognitive impairment, eloped from the Facility, and was found approximately 2 miles from the Facility, outside exposed to temperatures between 30 to 37 degrees Fahrenheit, for approximately 90 minutes, and sustained abrasions to his/her right knee, pain in both hips, a body temperature of 96.2 degrees F, and fatigue. Findings include: Facility policy titled Elopement Guideline, dated 10/2015, indicated, in the event of a missing resident who cannot be located on his/her respective unit, the staff person in charge will initiate a search of all areas of the Facility and external premesis, and all available employees will continue to participate in searching all areas of the Facility, as directed by the staff person in charge. If the missing person cannot be located, staff were to notify the resident's family or responsible party, notify the police, notify the resident's attending physician, complete the Missing Resident Profile, and attach a current photograph of the resident. Resident #1's [DIAGNOSES REDACTED]. After the incident of elopement, his/her spouse revealed he/she had a history of [REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation. A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied. Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times. A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and he/she was found at or around 8:35 P.M., by a staff member, approximately 2 miles from the Facility, had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, Nurse Practitioner #1 was notified, and orders for X-rays of the sites to rule out fractures was obtained. A Police Report, dated 11/21/16, indicated, it was reported to the Police at 7:52 P.M., that Resident #1 was missing from the Facility (approximately 52 minutes after Resident #1 was first noticed missing), on 11/21/16, and was located 30 minutes later by Facility staff. Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said Resident #1 was known to wander, was exit seeking, and a wanderguard bracelet was in place. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., he walked to the other 3 units of the Facility to ask if anyone had seen Resident #1 before making an announcement over the intercom. Nurse #1 said he could not recall what announcement he had made over the intercom. Nurse #1 said a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called the local Police Department about 15 minutes after first noticing Resident #1 was missing, (This was inconsistent with the Police report). Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 90 minutes after he/she was missing), walking along a main road, and was returned to the Facility. CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching for Resident #1. CNA #1 said there was not an announcement made over the intercom to alert staff that there was a missing resident. This was inconsistent with Facility policy and inconsistent with Nurse #1's statement. The Staff Development Coordinator (SDC) was interviewed at 4:03 P.M., on 12/14/16. The SDC said in the event of a missing resident, after a ten minute search has been conducted, the person in charge at the Facility should announce Code 10 to alert staff that a resident is missing. The Surveyor requested a written policy regarding the Facility's Code 10 procedure, however it was not produced. The Assistant Director of Nurses(ADON) was interviewed at 11:08 A.M., on 12/12/16. The ADON said the procedure when there is a missing resident is for the person in charge at the Facility to announce over the intercom system (name of resident) please return to your floor to alert staff throughout the building that a resident is missing, and to initiate a search, however she was unaware if there was a written protocol to this effect. This was inconsistent with the SDC's statement. The ADON said she was not aware of the Missing Resident Profile form, as mentioned in the Facility's Elopement policy. CNA #4 was interviewed at 11:17 A.M., on 12/14/16. CNA #4 said at or around 7:00 P.M., on or around 11/21/16, Resident #1 eloped from the Facility, and Nurse #1 notified staff by walking to the units, asking if staff had seen Resident #1. CNA #4 said there was not an announcement made over the intercom to alert staff of a missing resident. This was inconsistent with Facility policy, and Nurse #1's statement. CNA #4 said she did not know what Code 10 indicated. A review of the Facility's Elopement Book, which was located at the front desk, indicated, there were 11 residents identified at risk for elopement. The Administrator said the Elopement Book is updated weekly, however, 7 out of 11 of the residents identified at risk for elopement did not have a photograph documented for identification purposes. This was inconsistent with Facility policy. Each of the 11 residents identified at risk for elopement had a printed face sheet filed in the book, however, 4 out of the 11 face sheets were printed on the date of the survey, after the book was requested by the Surveyor. The Business Office Manager said it was the responsibility of the SDC to update the Elopement Book. The SDC said it was not her responsibility to update the Elopement book, and that it used to be the responsibility of a nurse who was once an evening shift supervisor, but now works day shift. Unit Manager #1 said the ADON and the SDC were responsible to update the Elopement Book. The ADON said she did not know whose responsibility it was to update the Elopement Book. The DON said she did not know whose responsibility it was to update the Elopement Book, and the Facility did not have a functioning camera available to update photographs.