Every finding on record at Dickson Health and Rehab

Based on policy review and interview the facility failed to ensure employment of a qualified Infection Preventionist to monitor and maintain the facility's Infection Prevention and Control Program. This had the potential to affected 65 of 65 residents residing in the facility. The findings include: Review of the facility policy titled, Infection Preventionist, dated 2/1/2026, revealed .The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program.whose primary role is to coordinate and be actively accountable for the facilities infection prevention and control program to include the antibiotic stewardship program.The IP [Infection Preventionist] will physically work on site in the facility.The IP must have obtained specialized IPC [Infection Control and Prevention] training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certification(s) of completion. The facility failed to ensure there was an IP at the facility to implement the facility's infection prevention and control program. During an interview on 5/27/2026 at 8:02 AM, in the Administrator's office, the Administrator (ADM) was asked who the IP was. The ADM stated, We do not have an IP, the Unit Manager has been doing the IP duties. The ADM was asked if the Unit Manager had an IP certification. The ADM stated, No. During an interview on 5/28/2026 at 9:20 AM, in the Administrator's office, the ADM was asked about not having a certified IP at the facility. The ADM stated, There was a Director of Nursing (DON) who was the IP. She was certified, her last day of work was 3/24/2026, and there has not been a certified IP at the facility since 3/24/2026. The ADM was asked if he was aware of any plans for getting a certified IP. The Administrator stated, They are wanting to get people certified.want it to be a Registered Nurse . The ADM was asked should the facility have an onsite certified infection preventionist. The ADM stated, Yes, per requirements.

Based on policy review, employee time sheet review, and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 11 of 31 days reviewed and failed to ensure the facility had an RN that was not the Director of Nursing (DON) when the census was above 60 for 7 of 31 days reviewed. The findings include: 1. Review of the facility policy titled, Nursing Services-Registered Nurse (RN), dated 10/2017, revealed .It is the intent of the facility to comply with Registered Nurse staffing requirements.utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week.The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. 2. Review of the employee time clock sheets dated 4/25/2026 through 5/24/2026, revealed there was no RN on duty for 8 consecutive hours on the following dates: a. 5/2/2026 b. 5/3/2026 c. 5/7/2026 d. 5/8/2026 e. 5/9/2026 f. 5/10/2026 g. 5/15/2026 h. 5/16/2026 i. 5/17/2026 j. 5/18/2026 k. 5/19/2026 The facility was unable to provide additional employee time sheets for the above dates as requested. 3. Review of the employee time clock sheets dated 11/30/2025, revealed the DON was the only RN on duty in the facility on that date. 4. Review of the employee time clock sheets dated 4/25/2026 through 5/24/2026, revealed the DON was the only RN on duty in the facility for the following dates: a. 5/7/2026 b. 5/13/2026 c. 5/14/2026 d. 5/19/2026 e. 5/20/2026 f. 5/21/2026 5. During an interview on 5/28/2026 at 10:30 AM, the DON confirmed there should be an RN on duty for 8 consecutive hours, 7 days a week. The DON was shown the time sheets and was asked if she covered any days as the only RN on duty. The DON stated, .Yes.I have.I understand that the census will affect whether I can be the only RN in the building for staffing.We just hired another full time RN.she has agreed to help if it doesn't look like they are going to be fully covered.

Based on policy review, medical record review, and interview, the facility failed to provide care to ensure that acceptable parameters of nutritional status were maintained and dietary recommendations were reviewed and implemented for 3 of 3 (Resident #2, #6, #7) residents reviewed for weight loss. The findings include: 1. Review of the undated facility policy titled, Weight Monitoring, revealed .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.The physician should be informed of a significant change in weight and may order nutritional interventions.The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. 2. Review of the medical record revealed Resident #2 was re-admitted to the facility on [DATE] with diagnoses including Diabetes (DM), Dementia, Malnutrition, Nausea with Vomiting, Dysphagia, Gastro-Esophageal Reflux Disease (GERD), Anxiety, and Adult Failure to Thrive. Review of the revised Care Plan dated 2/24/2026, revealed .Focus.[Resident #2] is at risk for impaired nutrition/weight r/t [related to] vitamin deficiencies, abnormal low BMI [body mass index], anemia, GERD, HLD [hyperlipidemia-high levels of fat in the blood], hx [history] of significant weight changes.Interventions.Monitor/record/ report to MD [Medical Doctor]. significant weight loss: 3lbs [pounds] in 1 week, >[greater than] 5% [percent] in 1 month, >7.5% in 3 months, >10% in 6 months.RD to evaluate and make recommendations PRN [as needed].Focus.resists her meals at times r/t to dementia, constipation, and vomiting.at risk for possible fluid balance flucation [fluctuation]/dehydration r/t Nausea, Vomiting.Has Magic Cup [a supplement option for adding nutrition, calories, and protein for those experiencing involuntary weight loss] in the evenings to support calorie intake.Interventions.RD to evaluate and make recommendations PRN.Weigh monthly and PRN 2/9/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #2 was noted for weight loss, not on a prescribed weight-loss regimen, and required staff setup with eating. Review of the Physician Order dated 1/27/2026, revealed Regular diet, Regular Texture .Thin consistency. Review of the Physician Order dated 1/27/2026, revealed Dietary supplements may be used when determined appropriate by IDT [Interdisciplinary Team] or RD [Registered Dietician]. Initiate specific order for resident. Review of the Physician Order dated 1/29/2026, revealed House Supplement Shake 4oz [ounces] two times a day Give 120mL [milliliters] orally twice per day with lunch and dinner . Review of the Nutrition: Dietary Complete Quarterly Manager Quarterly/Annual review dated 3/5/2026, revealed weight stable last 2 weeks, resident has a history of weight loss .4 oz [ounces] House Supplement .Rd recommended fortified potatoes @ [at] lunch & frozen nutritional treat @ supper. Staff offers snacks between meals & with food related activities . Review of the progress note dated 4/25/2026, revealed Note Text: RD Note.med pass 120 cc [cubic centimeter] BID [twice a day] started (1/26), increased Med pass TID [three times a day] recommended (4/22). Diet: Regular .Rsd [Resident] requests mushroom or chicken noodle soup w [with]/crackers to supper tray daily (does not always like what is served).Recommendations.d/c [discontinue] Med pass [a fortified nutritional supplement] 120 cc BID and start sugar-free Med pass 120 cc TID.Consider an appetite stimulant .Obtain weekly weights . There was no documentation the facility conducted a follow up on the dietary recommendation to increase the Med Pass to 120 cc to TID, obtain an order for the use of an appetite stimulate, or to perform weekly weights for Resident #2. Review of the progress note dated 5/6/2026, revealed Note Text.Current interventions include Thrive [dietary supplement], fortified potatoes at lunch, Thrive and soup at supper, and House supplement 4 oz BID. Visited Resident this AM [morning]; good intake of breakfast. Food preferences reviewed and updated.Recommendations .Add fortified potatoes at supper and provide gravy at lunch and dinner to enhance intake.Increase Med Pass to TID for additional caloric/protein support.Continue weekly weights for closer monitoring .Consider appetite stimulant as medically appropriate.Resident remains at high nutritional risk due to significant weight loss and underweight status. Will continue to monitor PO intake, weight trends, and response to interventions closely . There was no documentation the facility conducted a follow up on the dietary recommendation to increase the Med Pass to 120 cc to TID, the use of an appetite stimulate, or to perform weekly weights for Resident #2. During an interview on 5/27/2026 at 11:34 AM, the Interim DON was asked who receives the RD recommendations. The Interim DON stated, She sends them to us, they usually go to [Unit Manager]. The Interim DON was asked if the dietary recommendations should have been addressed or followed. The Interim DON stated, They should have and I've got to find out why they were not.We have weekly meetings with [the RD]. The Interim DON was asked if weight loss could potentially put a resident's health at risk. The Interim DON stated, It could. During an interview on 5/28/2026 at 10:52 AM, Physician F was asked how she is made aware of recommendations. Physician F stated, I talk to the DON and nurse managers about who needs to be seen and why. Physician F was asked if she had been made aware of the dietary recommendations made related to Resident #2's weight loss on 4/25/2026 and 5/6/2026. Physician F stated, I was made aware of them yesterday, I think the weight seemed to be better, we were going to keep her med pass at bid, her blood sugar is a concern. I talked to the DON yesterday, I will see her at bedside to follow, I didn't want to start something at this time. During an interview on 5/28/2026 at 11:32 AM, The Unit Manager was asked if she was made aware of the RD recommendations for Resident #2 on 4/25/2026 and 5/6/2026. The Unit Manager stated, I did receive those, I believe the Interim DON was tagged on those emails. The Unit Manager was asked who is responsible to make sure the Physician is made aware of the RD recommendations. The Unit Manager stated, Whoever received the email with the recommendation. During an interview on 5/28/2026 at 3:20 PM, the Medical Director was asked if he was made aware of the dietary recommendations related to weight loss for Resident #2 on 4/25/2026 and 5/6/2026. The Medical Director stated, Not directly .I don't recall noticing any weight loss or orders. The Medical Director was asked if he should have been made aware of recommendations regarding the resident's weight change. The Medical Director stated, Yes. The facility failed to notify the physician of RD recommendations for nutritional intentions on a resident with altered nutritional status and increased risk for weight loss. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Dementia, Anorexia, Moderate Protein-Calorie Malnutrition (body's inability to absorb nutrients resulting in inadequate nutrition) , Depression, Dehydration, Gastroesophageal Reflux Disease, Diabetes Mellitus, and Hypomagnesemia. Review of the Physician order dated 2/3/2026, revealed .dietary supplements may be used when determined appropriate by IDT [Interdisciplinary Team] or RD. Initiate specific order for resident. Review of the comprehensive Care Plan dated 2/4/2026, revealed .[Named Resident #6] .at risk for possible fluid balance fluctuation/ dehydration r/t [related to] Poor intake .is at risk for altered nutritional/hydration status r/t Alzheimer's, Dementia, appetite stimulant .will maintain nutritional status and body weight through the review date with no significant changes .Administer medications as ordered. Monitor for side effects and effectiveness .Encourage consumption of fluids provided .Monitor weights weekly r/t weight loss .Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth .Registered Dietitian [RD] to evaluate and make recommendations PRN .Weigh a minimum of monthly, as ordered, and PRN . Review of the admission MDS assessment dated [DATE], revealed Resident #6 scored 00 on the BIMS assessment, which indicated she was severely cognitively impaired. Resident #6 had a weight loss of 5 percent (%) or more in the last month or loss of 10% or more in last 6 months and complained of difficulty or pain with swallowing. Review of the Physician order dated 2/13/2026, revealed .magic cup or equivalent with lunch meal one time a day for supplement. Review of the Physician order dated 3/22/2026, revealed .resident receives the anti-depressant: REMERON The behavior associated with their depression is noted to be: INSOMNIA, DECREASED APPETITE. Review of the Physician order dated 4/30/2026, revealed .Regular diet, Finger Foods texture, Thin consistency Diet. Review of Nutrition Note dated 5/20/2026 at 12:03 PM revealed . A nutritional assessment was completed on this date for [Named Resident #6]. Resident with a history of weight changes. Resident's current diet order is therapeutically regular. Diet texture is regular. Resident's meal intakes are fair averaging 51-75%. Finger foods provided food preferences provided B: pancakes L: magic cup, fruit and dessert D: magic cup, fruit and dessert Per ADL documentation, resident is independent with eating. Per ADL documentation, resident requires set-up or clean-up with eating. Resident eats meals in dining room. Noted Remeron order, which may help stimulate appetite. Trialed Mighty Shake [nutritional, protein-rich shakes designed to add extra calories and essential nutrients to a person's diet] today; resident accepted and appeared to enjoy supplement. Recommend sending Mighty Shake with lunch daily to provide an additional 200 kcal and 6 g protein to support nutritional intake . There was no documentation the facility conducted a follow up on the dietary recommendation to send Might Shakes with Resident #6's lunch. During an Interview on 5/27/2026 at 3:27 PM, The RD was asked how often are you at the facility. RD stated, . at facility every Wednesday.I send recommendations every Wednesday.before I leave, I send RD recommendations and weekly weights .to Administrator, HR, DON, Unit Manager. The RD was asked if staff notified her of physicians' responses to her recommendations. The RD stated, .I don't know. The RD was asked if she was able to enter orders on the computer. RD stated, .I do not enter any orders in computer, I give recommendation, order entry is up to the provider. The RD was asked if she had weight loss meetings. The RD stated, .Weight loss meeting have been on Wednesday's at 1PM. The RD was asked who attended weight loss meeting. The RD stated, .MDS, Unit Manager, not sure who else is there.In meeting the recommendations can be taken care of then and there. The RD was asked if as RD she made recommendations should she be notified of the outcome of her recommendations. RD stated, .It would be nice in a perfect world.I'm hired to give a recommendation. The RD acknowledged she had made recommendations for Resident #6. The RD was asked if she was aware of any of her recommendations being implemented. The RD, stated .I'm not sure. During interview on 5/28/2026 at 9:22 AM, the Interim DON was asked if the facility has weekly IDT meeting. The Interim DON stated, .Yes. The Interim DON was asked if weight loss was discussed in these meetings. The Interim DON stated, .Yes, we talk with the RD and she gives recommendation.I was unaware that the recommendations were not being followed through on.I spoke with the RD and she showed me her documentation of recommendations and the RD is now going to make sure the kitchen manager, and myself have the information. During a phone interview on 5/28/2026 at 10:59 AM, Physician F was asked when she was made aware of the RD's recommendations for Resident #6. Physician F stated, .Yesterday was the first that I had heard about any recommendations from the RD .We use a different computer system and it is hard to find the RD's notes.In the future we will need to find a new way of relaying information. During phone interview on 5/28/2026 at 4:00 PM, the Medical Director was asked if he was familiar with Resident #6. The Medical Director stated .Yes .The Medical Director was asked if he was aware of the recommendations by RD. The MD stated .I didn't get the recommendations .RD recommendations should be put in computer and then I can sign off on them . There is an order in the computer dated 2/3/2026 that states: .Dietary supplements may be used when determined appropriate by IDT or RD. Initiate specific order for resident . The facility failed to notify the Physician of RD recommendations for nutritional intentions on a resident with altered nutritional status and increased risk for weight loss. 4. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Depression, Diverticulitis, and Edema. Review of the MDS assessment dated [DATE], revealed Resident #7 scored a 3 on the BIMS assessment, which indicated she was severely cognitively impaired. Resident #7 required setup or clean-up assistance from staff for eating and weight loss of 5% (precent), or more in the last month or loss of 10% or more in last 6 months, not on a physician prescribed weight loss program. Review of the Registered Dietician's Nutrition Note, dated 4/25/2026 at 19:18 [7:18 PM], revealed .Wt is up after significant loss +3.0% change over 30 days . Regular diet, Regular texture, ThinL [thin liquids], with poor intake .with many meal refusals.Will monitor weekly weights, restart Med pass [a fortified nutritional supplement], 120cc TID [three times per day], consider appetite stimulant for poor PO [by mouth] intake . There was no documentation the facility conducted a follow up on the dietary recommendation to start Med Pass supplements or an appetite stimulant. Review of the Care Plan revised care plan dated 5/2/2026, revealed, .at risk for altered nutritional / hydration status r/t increased confusion at times and history of diverticulosis.Honor food preferences and update.Monitor and record meal intakes.Offer snacks between meals and PRN .RD to evaluate and make recommendations PRN. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 scored a 5 on the BIMS assessment, which indicated she was severely cognitively impaired. Resident #7 required set up for eating and had a not prescribed weight loss of 5% (precent) or more in the last month or loss of 10% or more in last 6 months. Review of the Physician's Order Summary Report for May 2026 revealed there were no orders for Med Pass or an appetite stimulant. Review of the signed Physician's Order dated 5/27/2026, revealed Dietary supplements may be used when determined appropriate by IDT or RD. Initiate specific order for resident. Review of the signed Physician's Order dated 5/27/2026 , revealed Add supplement: Supplement Shake 4 oz [ounces] between meals and bedtime There was no documentation the facility conducted a follow up on the dietary recommendation to start Med Pass supplements or an appetite stimulant until 5/27/2026. During an interview on 5/27/2026 at 3:09 PM with the Interim Director of Nursing (DON), the Interim DON was asked if an order was needed for Med Pass. The Interim DON stated, .Yes. The Interim DON was asked if the recommendation for med pass, 120 cc, three times a day was started. The Interim DON stated, Resident #7 has an order dated 11/8/2025 for mighty shake [a nutritional supplement], 4oz [ounces] between meals and at bedtime. I do not see where the Med Pass was started . The Interim DON was asked if the provider was notified of the RD's recommendation for the 120 cc of Med Pass three times a day and to consider an appetite stimulant. The Interim DON stated, .I do not see where the provider was notified. The Interim DON was asked what she expected staff to do when the facility gets a recommendation from the RD. The Interim DON stated, .They will have to speak to the provider to get their verification and document what the provider said. If the provider agrees, the order should be transcribed. If the provider disagrees, they still need to document the rationale and notify the RD so that we will be on the same page. During an interview on 5/27/2026 at 3:37 PM, the RD was asked how she knew the recommendations were reviewed, the provider was notified, and orders were put in. The RD stated, I email the recommendations, weekly, to everyone. The RD was asked to explain everyone. The RD stated, The [named Administrator] [named staff] who is Human Resource, [Named Staff], I do not know her title, and [named, Certified Dietary Manager] and [named Unit Manager]. The RD was asked did she attend the weight loss meetings. The RD stated, I attend every Wednesday. The RD was asked if her recommendations and the response by the provider are discussed in the weight loss meetings. The RD stated, I do not know. The RD was asked did she expect to be notified of the providers response after the recommendations for 120 cc of med pass three times per day and appetite stimulant for [Resident #7]. The RD stated, My recommendations is what I was hired for. During an interview on 5/27/2026 at 4:48 PM, the Administrator (ADM) was asked whenever a recommendation was given by the RD what he expected staff to do. The ADM stated, .The recommendation goes to nursing, and the nurse will process the recommendation and will follow through with the recommendation with the NP [Nurse Practitioner] or physician. The nurse staff will talk through with IDT [Interdisciplinary Team-a professionals from two or more disciplines who actively collaborate, share decision-making, and coordinate their efforts]. If they have questions, the nurses will talk to the physician, or the RD can follow through with the NP or the physician regarding the recommendation. The ADM was asked how he would know if the RD's recommendations were addressed and followed up on. The ADM stated, .The recommendation should come up in clinical meetings . meetings are Monday through Friday. The ADM was asked who attended the clinical meetings. The ADM stated, .The attendees of the daily clinical meeting are the IDT team, which is Nursing, MDS [Minimum Data Set] Coordinator, Social Service, Dietary Manager, and Activities During an interview on 5/28/2026 at 11:40 AM, the Unit Manager was asked who was responsible for following up with the physician to ensure the physician received the RD recommendations. The Unit Manager stated, I would be the person. The Unit Manager was asked did she review the RD recommendations for Resident #7. The Unit Manager stated, I was working the cart that week. During an interview on 5/28/2026 at 12:10 PM, the Unit Manager was asked did she notify the provider of the RD's recommendations for 120 cc of med pass three times a day and to consider an appetite stimulant for Resident #7. The Unit Manager stated, No. During an interview on 5/28/2026 at 4:07 PM, the Medical Director was asked the process when recommendations come in from the RD. The Medical Director stated, The recommendation come in as an order, and I sign off on the RD recommendations.the recommendation [related to Resident #7] was not in the orders for me to review. The facility failed to notify the Physician of RD recommendations for nutritional intentions on a resident with altered nutritional status and increased risk for weight loss. During an interview on 5/27/2026 at 10:57 AM, the RD was asked to describe some interventions that may be used for residents. The RD stated, I go see them, I look at medication, diagnoses, fluid, look at the chart, look at resident, look at teeth, appetite, talk with them, observe a lunch or breakfast, talk with them, food first . add a fortified food, or preference, supplements med pass, mighty shakes, magic cup, for an appetite stimulate. I can make a recommendation for that or Vitamin D. The RD was asked who she makes aware of recommendations. The RD stated I put the copy of recommendations on [Unit Manager] desk, I email [the Administrator], [Social Services Director], [Unit Manager], [Interim Director of Nursing [DON], and [Dietary Manager]. The RD was asked who she would address the continued weight loss with. The RD stated, I would go to [the Administrator] or [Unit Manager]. I can do dietary changes too . The RD then stated, I am doing my part, it's not my job to babysit, I come every Wednesday, I am available, I meet with everyone. The RD was asked if she had addressed with anyone that her recommendations are not being followed. The RD stated, I'm not going to say anything. The RD was asked if a resident received her recommendations, could it make a difference regarding weight loss. The RD stated, Yes, I think it could. During an interview on 5/28/2026 at 12:45 PM the Unit Manager was asked who attends the weight loss meetings. The Unit Manager stated, .the Interim DON/MDS coordinator, Social Worker, Activities Director, Director of Therapy and RD who is only here on Wednesdays.RD is new to this facility .the previous RD would make recommendations directly to the MD and then place the order in computer .We thought the new RD was following this same process but have found out that she was not. RD is a contracted employee. The Unit Manager was asked if she followed up with the RD regarding the recommendations. The Unit Manager stated, .did not follow up to see if recommendation were implemented. The Unit Manager was asked how she was made aware of RD's recommendations. The Unit Manager stated, .I was made aware of recommendation through an email from RD .If it was a recommendation and approved by MD then it could be put in computer, RD was responsible for notifying MD of recommendation.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's orders for 5 of 7 (Resident #8, #13, #15, #17 and #60) residents and the facility failed to have orders for oxygen administration and tracheostomy care for 2 of 7 (Resident #62 and #70) reviewed for respiratory care. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician.Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Review MAR [Medication Administration Record] to identify medication to be administered . Review of the undated facility policy titled, Tracheostomy Care, revealed .facility will ensure that residents who need respiratory care .is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences .tracheostomy care will be provided according to physician's orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications .General considerations include .provide tracheostomy care per physician order .maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu bag [single patient use manual resuscitator] easily accessible for immediate emergency care . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure and Dependence on Supplemental Oxygen. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. She was receiving Oxygen Therapy. Review of the Physician's Orders dated 5/7/2026, revealed .2L BNC [Binasal Cannula- a tubing used to deliver oxygen through the nose] to keep oxygen saturation above 90% every shift for Hypoxia . Further review of the Physician Orders dated 5/7/2026 revealed, Change out O2 [Oxygen] nasal cannula [tube that delivers oxygen through the nose] one time a day every Sun [Sunday]. Review of the Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 revealed, Change out O2 nasal cannula one time a day every Sun had not been completed on 5/24/2026. During an observation in Resident #8's room on 5/26/2026 at 10:20 AM, 1:04 PM, and 4:15 PM revealed the nasal cannula was dated 5/11/2026. The facility failed to follow Physician's Orders when the nasal cannula was not changed on 5/17/2026 or 5/24/2026. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Dependence on Supplemental Oxygen. Review of the annual MDS assessment dated [DATE], revealed Resident #13 scored a 9 on the BIMS assessment, which indicated she was moderately cognitively impaired. She was receiving Oxygen Therapy. Review of the Physician's Orders dated 7/7/2025, revealed .2L BNC [Binasal Cannula- a tubing used to deliver oxygen through the nose] to keep oxygen saturation above 90% every shift for Hypoxia . Review of the Physician's Order dated 7/7/2025 revealed, Change oxygen tubing one time daily every Sun. Review of the TAR dated 5/1/2026 - 5/31/2027 revealed, Change oxygen tubing one time daily every Sun had not been completed on 5/24/2026. During an observation in Resident #13's room on 5/26/2026 at 10:42 AM, 1:06 PM and 4:17 PM revealed oxygen tubing dated 5/17/2026. The facility failed to follow Physician's Orders when the oxygen tubing was not changed on 5/24/2026. 4. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Dependence on Supplemental Oxygen. Review of the significant change MDS assessment dated [DATE], revealed Resident #15 scored an 11 on the BIMS assessment, which indicated she was moderately cognitively impaired. She was receiving Oxygen Therapy. Review of the Physician's Orders dated 5/7/2026, revealed .2L BNC [Binasal Cannula- a tubing used to deliver oxygen through the nose] to keep oxygen saturation above 90% every shift for Hypoxia . Review of the Physician's Orders dated 5/7/2026 revealed, Change out O2 nasal cannula one time a day every Sun. Review of the TAR dated 5/1/2026 - 5/31/2026 revealed, Change out O2 nasal cannula one a day every Sun was not signed out as completed on 5/24/2026. During an observation in Resident #15's room on 5/26/2026 at 10:16 AM, 1:16 PM, and 4:18 PM revealed the nasal cannula was dated 5/7/2026. The facility failed to follow Physician's Orders when the nasal cannula was not changed on 5/10/2026, 5/17/2026 and 5/24/2026. 5. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Dependence on Supplemental Oxygen. Review of the annual MDS assessment dated [DATE], revealed Resident #17 scored a 6 on the BIMS assessment, which indicated he was severely cognitively impaired. He was receiving Oxygen Therapy. Review of the Physician's Orders dated 5/7/2026, revealed .2L BNC [Binasal Cannula- a tubing used to deliver oxygen through the nose] to keep oxygen saturation above 90% every shift for Hypoxia . Review of the Physician's Orders dated 5/7/2026 revealed, Change out O2 nasal cannula one time a day every Sun. Review of the TAR dated 5/1/2026 - 5/31/20206 revealed, Change out O2 nasal cannula one time a day every Sun was signed not signed out as completed on 5/24/2026. During an observation in Resident #17's room on 5/26/2026 at 10:13 AM, 1:16 PM, and 4:18 PM revealed nasal cannula dated 5/17/2026. The facility failed to follow Physician's Orders when the nasal cannula was not changed on 5/24/2026. 6. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Left Tibia Fracture, Chronic Obstructive Pulmonary Disease, Diabetes, Anemia and Seizures. Review of the quarterly MDS assessment dated [DATE], revealed Resident #60 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Physician's Orders dated 5/6/2026, revealed .2L BNC to keep oxygen saturation above 90% every shift for Hypoxia . Review of the Physician's Orders dated 5/10/2026, revealed Change out 02 nasal cannula one time a day every Sun. Review of the TAR dated 5/2026, revealed staff failed to change and document the change out of O2 nasal cannula tubing on 5/24/2026. Observation in Resident #60's room on 5/26/2026 at 9:53 AM,11:54 AM, 4:05 PM, revealed resident lying in bed with O2 tubing dated 5/17/26 (5/17/2026). Observation in Resident #60's room on 5/27/2026 at 7:44 AM, revealed resident lying in bed appears to be sleeping, O2 tubing dated 5/17/26 (5/17/2026). The facility failed to follow Physician's Orders to change the oxygen tubing every Sunday (weekly). During an interview on 5/27/2026 at 11:03 AM, the Interim DON was asked how often should oxygen tubing be changed. The Interim DON stated, I would have to say that we would follow the physician orders or the facility policy. The Interim DON was asked should there be an order for the tubing to be changed. The Interim DON stated, Yes. The Interim DON was asked if she would expect oxygen tubing to have dates on them. The Interim DON stated, We usually just sign them out. During an interview on 5/27/2026 at 11:30 AM, the Unit Manager was asked if there is an order to change the nasal cannula weekly on Sunday, if it was expected that the nasal cannula would be changed every Sunday. The Unit Manager stated, Yes. 7. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Pharynx, Acquired Absence of Larynx, Diabetes, and Dependence on Supplemental Oxygen. Review of the admission note dated 3/30/2026, revealed .Resident admitted to facility from home due to needing house renovations to be completed .Resident has a Trach [Tracheostomy] 6.5 .order for 10L [liters] O2 . Review of the comprehensive care plan dated 4/1/2026, revealed .presence of a tracheostomy .will have no abnormal drainage around trach site through the review date .Ensure that trach ties are secured at all times .Give humidified oxygen as prescribed .Monitor the resident for complications such as unexplained removal of the tracheostomy, aspiration and the potential for respiratory infection .and airway complications such as tracheal infections, mucous plugging, tracheal erosion and stenosis .Monitor/document respiratory rate, depth and quality . Review of the admission MDS assessment dated [DATE], revealed Resident #62 had a BIMS score a 13, which indicated Resident #62 was cognitively intact. Tracheostomy care and oxygen therapy were not noted on the assessment. Review of the Physician's Order dated 5/7/2026, revealed .Trach: aerosol collar [used to deliver oxygen and moisture] with oxygen at 10 liters two times a day . Review of the Physician's Orders revealed there were no physician orders to provide care of Resident #62's tracheostomy until 5/27/2026. During an interview on 5/28/2026 at 9:22 AM, the Interim DON was asked if she was aware there were no trach care orders in the computer for Resident #62 from admission until 5/27/2026. The Interim DON stated .I was not aware there were no orders .as soon as I found that out, orders were put into the computer.this is something that slipped through the cracks, but I am working to make sure it doesn't happen again. During a phone interview on 5/28/2026 at 4:03 PM, the facility Medical Director was asked if Resident #62, who was admitted on [DATE], should have had tracheostomy care orders placed on admission. The Medical Director stated . Yes, I will take the blame for this . The Medical Director stated .Yes, she was on respite care, that turned into long term care .I signed off on orders that were entered 5/27/2026, for trach care .I take full responsibility .I should have put in orders for trach care on admission . 8. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disorder (COPD), Heart Failure, Chronic Respiratory Failure, Dependence on Supplemental Oxygen, Panic Disorder, and Depression. Review of the facility's Standing Physician Orders (dated 2/1/2026) were scanned into the resident's medical record after admission but were never entered onto the Medication Administration Record (MAR). The ordered revealed, .SHORTNESS OF BREATH .Elevate HOB [Head of Bed] 30-45 degrees every shift unless contraindicated .SHORTNESS OF BREATH .O2 [Oxygen], 2L Nasal Cannula, for O2 Sats 88% or less as needed for Hypoxia [insufficient oxygen supply in blood] or respiratory distress obtain O2 Sats .For reading of 88% start O2 at 2L/min nc [nasal cannula]. Notify MD [Medical Director] within 1 hour of starting O2 . An MDS assessment was not available due to the admission date of 5/19/2026, assessment was not completed, transmitted and accepted. Review of the progress note dated 5/19/2026, revealed .O2 via [by way of] nasal cannula at 4 liters to keep sats [saturation of oxygen in blood] above 90% . Review of the baseline care plan dated 5/20/2026, revealed no documentation of oxygen use. Review of the Physician's Orders dated May 2026 revealed there were no active orders for continuous oxygen administration for Resident #70. Review of MAR dated 5/19/2026 to 5/27/2026, revealed there were no orders for oxygen administration. Review of the admission progress note dated 5/21/2026, revealed .Patient has a diagnosis of COPD. She has O2 at 2L [liters]/min [minute] via nasal cannula . Review of the progress note dated 5/22/2026, revealed .Patient has a diagnosis of COPD. She has O2 at 2L/min via nasal cannula . Review of the progress note dated 5/23/2026, revealed .Patient has a diagnosis of COPD. She has O2 at 2L/min via nasal cannula . Review of the progress note dated 5/24/2026, revealed .Patient has a diagnosis of COPD. She has O2 at 2L/min via nasal cannula . Review of the progress note dated 5/25/2026, revealed .Patient has a diagnosis of COPD. She has O2 at 2L/min via nasal cannula . During an observation in Resident #70's room on 5/26/2026 at 9:40 AM, Resident #70 was sitting up in a wheelchair wearing a nasal canula connected to an oxygen tank on the back of the chair. The oxygen tank was set to 3L/min. During an observation in the dining room at 5/26/2026 at 11:58 AM, Resident #70 was sitting in wheelchair wearing a nasal canula connected to an oxygen tank set on 3L/min. During an observation in Resident #70's room on 5/26/2026 at 3:03 PM, Resident #70 lying in bed, wearing a nasal cannula connected to an oxygen concentrator set on 3 L/min. During an observation in Resident #70's room on 5/27/2026 at 9:23 AM, Resident #70 resident sitting up in bed wearing a nasal cannula connected to an oxygen concentrator set on 2.5 L/min. During an interview on 5/27/2026 at 10:20 AM, LPN C was asked if she could look in Resident #70's orders and tell me what the order was for oxygen administration. LPN C stated, I do not see an order in her chart, I will look at her hospital paperwork. There is an order for Oxygen on 3L in her hospital chart I will put that order in. LPN C was then asked who was responsible for entering orders for oxygen administration on admission. LPN C stated, Usually, those orders just populate but since we have a new system, it may not have transferred over. The provider also comes in within 2 days and adjusts or puts any new orders in. LPN C was then asked if she or any of the other nurses are currently assessing the resident on her oxygen administration. LPN C stated, Yes. LPN C was then asked where those assessments are being documented. LPN C stated, If the nurses are documenting it may be in the skilled nurses note. During an interview on 5/27/2026 at 11:03 AM, the Interim DON was asked if there should be an order in a resident's chart if the resident is being administered oxygen. The Interim DON state, Absolutely. The Interim DON was asked if oxygen administration should be signed on the MAR when being administered. The Interim DON stated, Yes. The Interim DON was asked how you can be sure a resident is receiving the correct oxygen administration rate if there is not an order. The Interim DON stated, We can't assume the correct administration rate. We would have to call and get an order. The Interim DON was asked who was responsible for putting these orders in on admission when a resident is receiving continuous oxygen. The Interim DON stated, The Unit Manager puts them in, if it's on day shift and she is present, and the receiving nurse checks behind to verify orders are correct. If on night shift and the Unit Manager is not available, the receiving nurse puts the orders in, and the Unit Manager checks behind that nurse to make sure they are correct. If it is a weekend, we have a weekend RN [Registered Nurse] manager that puts them in and then they are verified by the receiving nurse. The Interim DON was asked would you expect your nurses to check orders to make sure the resident is receiving correct administration of oxygen. The Interim DON stated, Absolutely.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 1of 1 (Licensed Practical Nurse (LPN) A) nurses failed to perform hand hygiene between glove changes for 1 of 2 (Resident #32) sampled for wound care and when 1 of 3 (LPN B) nurses failed to wear Personal Protective Equipment (PPE) during enteral medication administration for 1 of 1 (Resident #62) sampled resident observed for medication administration by way of (via) percutaneous endoscopic gastrostomy (PEG) tube The findings include: 1. Review of the undated facility policy titled, Enhanced Barrier Precautions (EBP) revealed .To implement enhanced barriers precautions for the prevention of transmission of multidrug-resistant organisms .All staff receive training on enhanced barrier precautions upon hire and at least annually.An order for EBP will be obtained for residents with any of the following: wounds.feeding tubes.indwelling medical devices. 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Moderate Protein-Calorie Malnutrition, and Pressure Ulcer of Right Buttock, Stage 4. Review of the Physician Order dated 1/28/2026, revealed .Cleanse RIGHT buttock with Dakin [an antiseptic] solution, pat dry, apply collagen [a protein used to promote wound healing] powder, alginate with silver [used to provide absorption and antimicrobial properties in a single dressing] and cover with dry dressing once daily and prn [as needed] . Review of the care plan dated 3/23/2026 revealed .[Resident #32] is at risk for impaired skin integrity and pressure ulcer development r/t [related to] incontinence and impaired mobility.has pressure injury to right buttock. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed, Resident #32 was noted for severely impaired cognitive skills for daily decision making, dependent of staff for eating, toileting, bed mobility, and transfer, always incontinent of urinary and bowel, noted for 1 stage 4 pressure ulcer, and hospice care. Observation in Resident #32's room on 5/27/2026 at 4:17 PM, LPN A donned a gown and surgical mask, knocked on the door, sanitized hands and donned gloves. Registered Nurse (RN) D was in the room, with gown, gloves and mask on. RN D assisted positioning Resident #32 onto her right side during wound care. No dressing noted to wound area related to it had come off. LPN A cleaned the wound bed using gauze and Dakins, removed gloves, gloves and gauze placed in red bag, donned clean gloves without performing hand hygiene, area pat dry using gauze, removed gloves, donned clean gloves without performing hand hygiene, collagen powder and silver alginate applied to wound bed, bordered gauze applied. LPN A removed gloves and donned clean gloves without performing hand hygiene to assist with turning the resident. LPN A then removed the gloves, gown, and mask. LPN A sanitized hands. During an interview on 5/27/2026 at 4:42 PM, LPN A was asked when hand hygiene should be performed. LPN A stated, Every time you come in and out of a patient's room, if you used the restroom, and anytime you touch anything contaminated. LPN A was asked if hand hygiene should be performed between all glove changes. LPN A stated Yes. LPN A was asked if she had performed hand hygiene between all glove changes during wound care. LPN A stated No. During an interview on 5/28/2026 at 9:50 AM, the Director of Nursing (DON) was asked when staff should perform hand hygiene. The DON stated, Before going into a room and when coming out as well, after brief changes, and before serving food and medicine. The DON was asked if staff should perform hand hygiene between gloves changes. The DON stated, They should. The DON was asked if not performing appropriate hand hygiene could create the risk of contamination or infection. The DON stated, It can. 3. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Pharynx, Acquired Absence of Larynx, Diabetes, and Dependence on Supplemental Oxygen. Review of the Physician Order revealed no orders for Enhanced Barrier Precautions. Review of the Physician Order dated 3/31/2026, revealed LORazepam Oral Tablet 1 MG [milligram] (Lorazepam) .Give 1 mg .every 6 hours as needed for Generalized anxiety . During an observation in Resident #62's room on 5/27/2026 at 10:48 AM, LPN B performed hand hygiene, pulled medication from narcotic drawer, signed out the medication, put the medication in a pill pouch, crushed the medication and placed the medication in medication cup. LPN B pulled 6 syringes of 10cc (cubic centimeters) water, knocked on door and let resident know who she was and purpose of visit, donned gloves, and verified g-tube (tubing used for supplemental feedings) placement via auscultation. LPN B placed syringes on barrier on the over bed table, then flushed g-tube with 30 ccs water prior to giving medications, administered Lorazepam 1mg mixed with water, flushed with 30 ccs. All medications flowed via gravity without issue. LPN B placed syringe in plastic bag and placed on bedside table. LPN B removed gloves then washed hands with soap and water. LPN B failed to wear proper PPE during medication administration. During an interview on 5/27/2026 at 11:34 AM, LPN B was asked if she should have worn isolation gown while administering medications to resident who was in EBP. LPN B replied, Oh my gosh, Yes I guess I should have. During an interview on 5/27/2026 at 11:52 AM, the Interim DON was asked would you expect your nurses to wear an isolation gown while administering medications to a resident that is in EBP. The DON stated, Yes, I would.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 5 (Licensed Practical Nurse (LPN) A and LPN B) nurses left 2 of 6 (North Hall medication cart and North Hall treatment cart) medication storage areas unsecured and unattended. The findings include: 1. Review of the undated facility policy titled, Medication Storage, revealed .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.Only authorized personnel will have access to the keys to locked compartments.During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Narcotics and Controlled Substances.Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key.Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. Review of the undated facility policy titled, Controlled Substance Administration and Accountability, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances.Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel.Areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks. 2. During an observation and interview at the North Hall Nurse's station on 5/27/2026 at 10:00 AM, the North Hall Medication cart was noted to be unlocked and unattended. LPN B was noted to be sitting behind the nursing desk, out of sight of the medication cart. LPN B was asked should their medication cart be locked when out of view. LPN B stated, It's not locked? Yes, it should be. During an interview on 5/27/2026 at 10:04 AM, the Interim Director of Nursing (DON) was asked if she would expect the medication carts to be locked if unattended. The Interim DON stated, Absolutely, yes. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Moderate Protein-Calorie Malnutrition, and Pressure Ulcer of Right Buttock, Stage 4. Review of the Physician Order dated 1/28/2026, revealed .Cleanse RIGHT buttock with Dakin [an antiseptic] solution, pat dry, apply collagen [a protein used in wound care to promote tissue repair] powder, alginate with silver [used to provide absorption and antimicrobial properties in a single dressing] and cover with dry dressing once daily and prn [as needed] . Review of the care plan dated 3/23/2026 revealed [Resident #32] is at risk for impaired skin integrity and pressure ulcer development r/t (related to) incontinence and impaired mobility.has pressure injury to right buttock. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed. Resident #32 was noted for severely impaired cognitive skills for daily decision making, dependent of staff for eating, toileting, bed mobility, and transfer, always incontinent of urinary and bowel, noted for 1 stage 4 pressure ulcer, and hospice care. During an observation and interview at the North Hall Nurse's station on 5/27/2026 at 4:21 PM, revealed LPN A approached the North Hall Treatment Cart that was stored behind the Nurse's desk unattended and unlocked. LPN A removed a package of collagen powder wound filler, a package of calcium alginate with silver, a bottle of Dankin solution, gauze, and a 4x5 inch bordered gauze dressing to perform wound care for Resident #32. LPN A was asked if the treatment cart was locked. LPN A stated .I don't think so. LPN A was asked if it should have been locked. LPN A stated Yes. During an interview on 5/28/2026 at 9:50 AM, the DON was asked if medication carts should be locked when unattended. The DON stated Yes, locked at all times. The DON was asked if that included treatment carts. The DON stated, We lock those as well.

Based on policy review, Center for Disease Control (CDC) Guidelines, Enhanced Barrier Precaution (EBP) Signage, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were maintained when 3 of 6 (Certified Nursing Assistants (CNA) D, L, and O) staff members failed to perform hand hygiene during meal pass and placed dirty trays on the cart with clean trays and when Personal Protective Equipment (PPE) was not used or contained appropriately. The facility failed to don PPE when performing wound care for 2 (Resident #1 and Resident #8) of 4 residents reviewed. The findings: 1. Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA) (Isolation) (Contact, Enhanced, Airborne, Droplet), dated 4/2024, revealed .Transmission Based Precautions will be initiated when there is a reason to believe that a resident has a communicable infectious disease .When Transmission Based Precautions are implemented, the following is recommended .Ensure the appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room . Review of the facility policy titled, Hand Hygiene, dated 10/2024, revealed .This facility considers hand hygiene the primary means to prevent the spread of infection .Employees must wash their hands .before and after direct resident contact .before and after assisting a resident with meals .after contact with objects . in the immediate vicinity of the resident .after removing gloves . Review of the CDC Guideline revealed .Residents in nursing homes are at increased risk of becoming colonized with or developing infections caused by multidrug resistant organisms (MDROs). Studies show that more than 50% of nursing home residents may be colonized with an MDRO, and when MDROs result in infection, limited treatment options may be available. EBP [Enhanced Barrier Precautions] require staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or transmitting an MDRO. This includes: Residents known to be infected or colonized with an MDRO; Residents with an indwelling medical device including central venous catheter, urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status; and, Residents with a chronic wound, regardless of their MDRO status . Review of Enhanced Barrier Precautions (EBP) signage revealed .Providers and Staff must wear gloves and a gown for the following High Contact Resident Care Activities .dressing, bathing, transferring, changing linens, providing hygiene, changing briefs .device care or use .urinary catheter, feeding tube .Wound Care: any skin opening requiring a dressing . 2. Observations during dining on the [NAME] Hall on 3/3/2025 at 12:52 PM, revealed CNA L applied gloves without performing hand hygiene then exited the room without removing the gloves. Observations during dining on the [NAME] Hall on 3/3/2025 at 1:08 PM, revealed CNA O placed the tray on the resident's bed, removed dirty items from table and threw in garbage, removed the dirty tray from the bed and placed it back on the clean cart, and did not perform hand hygiene. Observations during dining on the [NAME] Hall on 3/3/2025 at 1:12 PM, revealed CNA O adjusted resident's bed, and assisted resident with meal without performing hand hygiene. During an interview on 3/5/2025 at 10:02 AM, the Director of Nursing (DON) was asked if hand hygiene should be performed before putting on gloves. The DON replied, Yes. The DON confirmed that dirty trays should not be placed on the cart with clean trays. 3. Review of medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Diabetes, Heart Failure, and Hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #38 was moderately cognitively impaired. Review of the Physician Orders dated 3/2/2025, revealed .Contact isolation every shift for infection control . Review of the Progress Notes dated 3/2/2025 at 23:07 revealed .Resident was then tested for Covid and test results came back positive. Covid isolation precautions started . Observations in Resident's room on 3/3/2025 at 10:44 AM and 3:56 PM, and on 3/4/2025 at 7:57 AM, revealed droplet precaution sign on door, red biohazard bag laying in floor with used personal protective equipment [ppe] inside it. During an interview on 3/5/2025 at 10:02 AM, the Director of Nursing (DON) was asked if the red biohazard bag with dirty PPE in it should be laying in the floor in the resident's room. The DON replied, NO. 4. Review of medical records revealed Resident #1 was admitted to facility on 5/1/2008, with diagnoses which include Cerebral Palsy, Dementia and Osteoarthritis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 00 which indicated Resident #1 was severely cognitively impaired. Review of Order Review History Report dated 2/5/2025 - 3/5/2025, revealed an order for .Treatment Stage 3 right buttock: Cleanse with wound cleanser, pat dry apply Leptospermum honey, cover with bordered gauze daily and PRN. Every shift for wound healing . Review of Care Plan revealed Resident #1 had developed a pressure injury to her right buttock. Observation on 3/6/2025 at 11:00 AM, revealed LPN K performing wound care and was assisted by CNA T. There was no EBP caddy located on the door and LPN K and CNA T did not don PPE during treatment. 5. Review of medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which include Dysphagia, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus. Review of the Care Plan dated 12/13/2024 revealed Resident #8 has .history of recurrent Urinary Tract Infections [UTIs] [secondary to ESBL] .had Diabetic Ulcer related to Diabetes .left dorsal foot .left forth toe .right 3rd toe .right 2nd toe .left lateral foot . Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 9 which indicated moderately cognitively impaired. Review of the Order Review History Report dated 2/6/2025 - 3/5/2025, revealed Resident #8 had an order for .Enhanced Barrier Precautions: Positive for ESBL in urine contact precaution .Treatment Skin Tear to bottom left foot at pinky toe at base of foot: Cleanse wound with wound cleaner, pat dry, cover with calcium alginate, gauze and tape. Change daily and prn until healed . Observation on 3/6/2025 at 10:45 AM, revealed LPN K performed wound care and did not don PPE. During random interviews on 3/6/2025 at 11:48 AM through 12:05 PM, CNA U, LPN N and LPN Q were asked what EBP would be used for. Neither staff member was able to provide a correct response to the proper reasons why a resident would be on Enhanced Barrier Precaution. 48285 49311

Based on policy review, review of facility Infection Surveillance monitoring documents, and interview, the facility failed to establish and implement a program to identify, report, investigate and control infections and communicable diseases when staff (Licensed Practical Nurse (LPN) G) failed to track organisms being treated in the facility and monitor for outbreaks and cross contamination. This had the potential to affect 62 of 62 residents in the facility. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, revised 1/2024, revealed .The community Infection Prevention and Control Program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The program establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors . 2. Review of the undated map provided with the December 2024 Infection monitoring reports revealed the following infections in the facility in December 2024: 4 Respiratory infections 4 skin infections and 2 Urinary Tract Infections (UTIs). Review of the Infection Surveillance Monthly Report dated December 2024 revealed residents received antibiotics for the following infections: 1 Eye, Ear, Nose Mouth Infection, 1 Gastrointestinal, 15 Other infections, 5 Respiratory, 4 Skin and soft tissue, and 7 UTIs. None of the 7 Residents listed as having a UTI had the organism being treated listed on the report or the map. 3. Review of the undated map provided with the January 2025 Infection monitoring reports revealed the following infections in the facility in January 2025: 1 Ear Nose and Throat infection, 5 skin infections, 15 UTI's, 10 Respiratory infections, and 3 Eye Infections. Review of the Infection Surveillance Monthly Report dated January 2025, revealed residents received antibiotics for the following infections: 1 Ear, Nose, Mouth and Throat infection, 1 Eye infection, 1 Gastrointestinal, 1 Multi Drug Resistant Organism (MDRO), 17 Other types of infection, 10 Respiratory infection, 5 skin and soft tissue infections, and 11 UTI's. None of the 11 residents being treated for UTIs had the organisms being treated listed on the report or the map. 4. Review of an undated map provided with the February 2025 Infection monitoring reports revealed the following infections were present in the facility in February 2025: 1 skin infection, 7 Respiratory infections, 11 Urinary Tract Infections, and 1 eye infection in the facility. Review of the Infection Surveillance monthly Report dated February 2025 revealed residents listed on the report received antibiotics for the following infections: 1 eye infection, 1 MDRO, 1 Other type of infection, 5 Respiratory infections, 1 skin and soft tissue infection and 2 UTIs. None of the residents listed on the report had orders for antibiotic orders written in February. The 3 residents being treated for UTIs did not have the organisms being treated listed on the report or the map. 5. During an interview on 3/5/2025 at 3:04 PM, LPN G was asked if Urinary Tract Infections are monitored by which organism were on what hall or in what area of the facility. LPN G stated, We don't do that. LPN G was asked how you monitor for cross contamination or outbreaks. LPN G stated, I don't . LPN G was asked, do you know what types of bacteria you would isolate for. LPN G stated, Not off top of my head, I would look where I'm doing my training, I'm not certified yet . During an interview on 3/6/2025 at 10:00 AM, LPN G confirmed that the information on the map for February did not match the information in the monthly surveillance form. LPN G confirmed the information is not pulling from the electronic medical record system to the report correctly and that this was not identified until yesterday (3/5/2025). During an interview on 3/6/2025 at 10:14 AM, the Administrator was asked do you expect infections to be tracked to monitor for trends and cross contamination. The Administrator replied, Yes ma'am.

Based on review of the Centers for Medicare & Medicaid Services guidelines and interviews the facility failed to provide a qualified Infection Control Preventionist who was responsible to monitor and maintain the facility's Infection Prevention and Control Program. This could have affected 62 out of 62 residents currently residing in the facility. The findings include: 1. Review of the Centers for Medicare & Medicaid Services factsheet titled, Updated Guidance for Nursing Home Resident Health and Safety, dated June 29, 2022, revealed . Requires facilities have a part-time Infection Preventionist (IP) .While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility . The IP must physically work onsite and cannot be an off-site consultant or work at a separate location . IP role is critical to mitigating infectious diseases through an effective infection prevention and control program .IP specialized Training is required and available . 2. During an interview on 3/5/2025 at 3:04 PM LPN G was asked, do you know the types of bacteria you would isolate for. LPN G stated, .I would look where I'm doing my training, I'm not certified yet . During an interview on 3/5/2025 at 4:23 PM LPN G was shown the Training Plan Proof of Completion and confirmed that she had completed the training but has not passed the Certification Test. During an interview on 3/6/2025 at 10:14 AM the Administrator was asked how long the facility has been without a certified Infection Preventionist. The Administrator stated, .2/6/2025.

Based on policy review, kitchen sanitation logs, refrigerator temperature logs, observation, and interview, the facility failed to ensure food was served under sanitary conditions when the kitchen floor was dirty with pieces of paper scattered on the floor, a black rubber floor mat was sticky and had crumbs and particles under it, the deep fryer had a sticky build up, the oven handles were sticky and the oven had crumbs in it, and 3 dry food storage bins had crumbs and thick sticky area in the outer edge of the lids. The facility failed to log refrigerator temperatures on the nutrition refrigerator and had an undated item in it. The facility had a census of 62 with 62 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled Refrigerators and Freezers, dated 10/2024, revealed .Monthly tracking sheets will include time, temperature .and initials .employees will check and record refrigerator and freezer temperatures daily . Review of the facility policy titled Sanitation, dated 10/2024, revealed .The food service area shall be maintained in a clean and sanitary manner .kitchen areas .shall be kept clean .Utensils, counters, shelves and equipment shall be kept clean .The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas .Food service staff will be trained to maintain cleanliness throughout their work areas during all talks, and to clean after each task before proceeding to the next assignment . 2. Observation in the kitchen on 3/3/2025 at 9:05 AM with [NAME] V revealed the following: Oven handles were sticky, the inside of the oven was dirty with dried food, the floor was dirty with small pieces of paper throughout the kitchen floor, the deep fryer had dried oil on the outside caked on the back, 3 dry goods container lids had a greasy build up and crumbs, there were crumbs on the shelf of the prep table across from the oven, and liquid eggs undated in plastic bag sitting in dirty water in a plastic bin. During an interview on 3/3/2025 at 9:35 AM, [NAME] V was shown the dried grease and crumbs on the dry good bins. [NAME] V was asked if the liquid eggs should be undated sitting in dirty water in the refrigerator. She replied, No . 3. Observation in the kitchen on 3/4/2025 at 9:58 AM revealed the rubber mat in the dish wash area was very sticky with a lot of crumbs underneath that could be seen through the holes in the mat, the floor under the dishwasher table was dirty with dried white liquid and crumbs, the dry goods bins still with sticky build up and crumbs, the oven handles were still sticky, deep fryer still had dried oil on the outside and caked on the back, and dried sticky substance and crumbs in utensil drawer. During an interview on 3/4/2025 at 10:23 AM the Registered Dietician (RD) confirmed the kitchen should be clean. 4. Review of the February and March 2025 cleaning schedule duties dated 2/2/2025 through 3/8/2025, assigned for the 5:00 AM cook, the 5:00 AM aide, the 6:00 AM aide, the 11:30 AM cook, and the 11:30 AM aide, had multiple blank areas that were not initialed as having been performed. There were no cleaning logs dated after 3/8/2025. The 5:00 AM cook failed to initial the following dates 2/2/2025 through 2/13/2025, 2/15/2025, 2/16/2025, 2/29/2025 through 3/3/2025 and 3/5/2025 through 3/8/2025. The 5:00 AM aide failed to initial the following dates 2/2/205 through 2/20/2025, 2/22/202025 through 3/2/2025 and 3/4/2025 through 3/8/2025. The 6:00 AM aide failed to initial the following dates 2/2/205, 2/7/2025 through 2/9/2025, 2/12/2025 through 2/27/2025, and 2/20/202025 through 3/8/2025. The 11:30 AM cook failed to initial the following dates 2/2/2025, 2/4/2025 2/5/2025, 2/7/2025 through 2/16/2025, 2/18/2025 through 2/20/2025, 2/22/2025 through 3/4/2025 and 3/6/2025 through 3/8/2025. The 11:30 AM aide failed to initial the following dates 2/2/2025 through 2/6/2025, 2/8/2025, 2/12/2025, 2/14/2025 through 2/22/2025 and 2/27/2025 through 3/8/2025. During an interview on 3/4/2025 at 12:28 PM, the Registered Dietician (RD) confirmed the cleaning logs should be initialed after the assignments are completed. 5. Observation and interview on 3/4/2025 at 3:04 PM the [NAME] Nutrition .Refrigerator Log .March 2025 had no temperatures recorded on the log. There was 1 pint of chocolate ice cream with not dated. The RD was asked if items in the nutrition refrigerator should be dated. RD stated, Yes. the RD also confirmed the temperature log should be filled out daily.

Based on the facility policy, facility list of residents that wander, medical record review, observation and interview the facility failed to provide an environment free of accident hazards for 1 of 21 (Resident #34) sampled residents when nursing staff left razors open and unattended on a table in Resident #34's room. The findings include: 1. Review of the facility policy titled, Needlesticks and Cuts, dated 4/2024 revealed, .Personnel will follow our facility's established procedures to help prevent injuries caused by .sharp blades, broken glass, or other sharp instruments or devices .Staff shall place .sharp objects in puncture-resistant containers . 2. Review of the facility list of residents that wander revealed 5 residents that frequently wander within the facility. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses which included Unspecified Systolic Congestive Heart Failure, Muscle Weakness, Unsteadiness on feet, Need for Assistance with personal care, and Restlessness and Agitation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continue review revealed Resident #34 required supervision with shower/bath and personal hygiene. Observation in Resident #34's room on 3/3/2025 at 10:10 AM and 3:32 PM, revealed 2 blue disposable razors on his nightstand. Observation in Resident #34's room on 3/4/2025 at 8:28 AM, revealed 2 blue disposable razors on his nightstand. Observation and interview in Resident #34's room on 3/4/2025 at 8:30 AM, Certified Nursing Assistant (CNA) D and CNA L acknowledged the open razors on the table and stated, .we are not supposed to have razors in the room, they should be in the shower room or central supply . The CNAs were asked why the razors should be kept in a secured area. CNA L stated, .for the safety of our residents, any type of sharp is dangerous . During an interview on 3/4/2025 at 8:33 AM, Licensed Practical Nurse (LPN) N stated, .razors should be in central supply or placed in sharps box, we do have residents that wander on this hall . During an interview on 3/5/2025 at 2:00 PM the Administrator was asked if razors should be in a resident's room. The Administrator stated, .No .residents shouldn't have them in the room .the razors should be locked in the shower room .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete resident assessments, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process, within the regulatory time frames for 2 of 21 sampled residents (Resident #28 and #48) reviewed for completion of the MDS resident assessments. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.19.1 October 2024, page 5-2 revealed . For the Admission assessment, the Care Area Assessment (CAA) Completion Date .must be no later more than 13 days after the Entry Date .For the Annual assessment, the CAA Completion Date .must be no later than 14 days after the ARD 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Contractures of Bilateral Lower Legs, Depression and Anxiety. Review of the annual MDS with an Assessment Reference Date (ADR) of 12/13/2024, revealed a completion date of 1/13/2025. The annual assessment should have been completed by 12/27/2024. During an interview on 3/5/2025 at 3:06 PM, the Senior Director of Clinical Reimbursement confirmed the MDS submission was not timely. 3. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, End Stage Renal Disease, Chronic Pain Syndrome and Diabetes. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15 which revealed Resident #48 was cognitively intact. Special procedure included Dialysis. Occasional incontinence of bladder and always incontinent of bowel. Surgical wound and dressing to feet. Medications included antipsychotics, antibiotics, and opioids. Review of the discharge MDS dated [DATE], revealed a completion date of 3/3/2025 that had not been submitted. During an interview with the 3/5/2025 3:11 PM, the Senior Director of Clinical Reimbursement confirmed the MDS submission was not timely.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop comprehensive care plans for 2 of 21 (Residents #55 and #215) sampled residents. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .if a history of trauma, interventions for care that address such based upon known interventions from qualified professions, and interventions that the staff may use to eliminate or mitigate triggers that may cause re-traumatization .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated with identified problems .The Care Planning/Interdisciplinary is responsible for the periodic review and updating of care plans .When there has been a significant change in the resident's condition . at least quarterly. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Pain Syndrome, and Post-Traumatic Stress Disorder (PTSD). Review of Resident #55's Comprehensive Care Plan with revision dated 8/4/2024, revealed a focus for Alcohol Dependence, Insomnia, Impaired Visual Function, ADL (Activities of Daily Living) Self care Performance, and needs encouragement and assistance to activities. The Comprehensive Care Plan did not address Resident #55's Chronic Pain Syndrome or Post Traumatic Stress Disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Resident required supervision or touching assistance with bed mobility, setup or clean-up assistance with eating, and dependent with toileting and transfers. Resident #55 was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #55's Psychiatry Progress notes dated 1/16/2025, revealed Anxiety, PTSD, Adult Failure to Thrive, Alcohol Induced Dementia, Manipulative Personality/ Mood Disorder, and Insomnia stable at present. During an observation on 3/4/2025 at 7:55 AM, Resident #55 was in his bed with call light in reach. During an interview on 3/6/2025 at 10:09 AM, the Director of Nursing (DON) was asked if a resident had a diagnosis of PTSD, should that be addressed on the care plan and she stated, .Yes . The DON was asked if a resident experienced pain should that be addressed on the care plan and she stated, Yes. 3. Review of the medical record revealed Resident #215 was admitted to the facility on [DATE], with diagnoses which included Wedge Compression Fracture of T7 - T8 (break in the vertebrae located at the 7th and 8th thoracic level of the spine), Wedge Compression Fracture of T11-T12 (break in the vertebrae located at the 11th and 12th thoracic level of the spine), Acute Respiratory Failure, Unspecified Cirrhosis of Liver, and Chronic Systolic Congestive Heart Failure. Review of the Comprehensive Care Plan dated 2/21/2025, for Resident #215 revealed a focus for the two areas of transfer status and risk for altered nutritional/hydration status. No further care plan problems were noted on the Comprehensive Care Plan. Review of Resident #215's Admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated no cognitive impairments. Continued review revealed Resident #215 was dependent for toileting, shower/bathe, dressing, and personal hygiene. Continued review revealed Resident #215 was always incontinent of bowel and bladder, frequently experienced pain, history of falls, and admitted with a Stage 4 pressure ulcer. Resident #215's Care Area Assessment (CAA) Summary (triggered care areas to indicate whether to care plan) dated 3/4/2025, revealed ADL (Activities of Daily Living) function, Urinary Incontinence, Falls, Pressure Ulcer, and Pain was triggered and a decision to care plan was marked. During an observation and interview on 3/5/2025 at 9:25 AM, Resident #215 was in the bed. Resident #215 was asked if she had any skin issues. Resident #215 stated, .I have a sore on my bottom, and it hurts me. During a telephone interview on at 3/5/2025 at 11:15 AM, Regional Registered Nurse (RN) stated, .since the end of January the facility has been without an MDS Coordinator, I just oversee that they are setting up the appropriate assessments and making sure their assessments are completed . Regional RN was asked to review Resident #215's CAA Summary dated 3/4/2025. Regional RN stated, .the facility should be going by the CAA Summary and proceed to care plan per the assessment. 51365

Based on policy review, medical record review, and interview, the facility failed to update or revise the care plans for 4 of 21 (Resident #55, #56, #57, and #220) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . If a history of trauma, interventions for care that address such based upon known interventions from qualified professions, and interventions that the staff may use to eliminate or mitigate triggers that may cause re-traumatization .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated with identified problems .The Care Planning/Interdisciplinary is responsible for the periodic review and updating of care plans .When there has been a significant change in the resident's condition .At least quarterly . Review of the facility policy titled, Using the Care Plan, dated 10/2024, revealed .The care plan shall be used in developing the resident's daily care routines and will .Changes of Condition should be reported .care plans update accordingly .Changes in the resident's condition will be reported . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Alcohol Dependence, Adult Failure to Thrive, and Post-Traumatic Stress Disorder (PTSD). Review of the care plan dated 6/14/2024, with a last revision date of 1/23/2025, revealed there were no focus/problems or interventions on the care plan for risk related to PTSD. Review of the quarterly MDS dated [DATE], revealed Resident #55 had a BIMS score of 9, which indicated moderately impaired cognition, required staff assistance with Activities of Daily Living (ADLS), and an active diagnosis of PTSD. During an interview on 3/6/2025 at 10:09 AM, the DON confirmed that a diagnosis of PTSD should be addressed on Resident #55's Care Plan. 3. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Pneumonia, Severe Sepsis without Septic Shock, Acute Respiratory Failure, and Hemiplegia and Hemiparesis. Review of the Admission MDS dated [DATE], revealed Resident #56 had a BIMS score of 13, which indicated intact cognitive abilities. Continued review revealed Resident #56 required supervision for eating, substantial/maximal assistance with toileting, shower/bathing, dressing and was always incontinent of bowel and bladder. Further review revealed Resident #56 had history of falls and was at risk for pressure ulcers. Review of Resident #56's Care Area Assessment (CAA) Summary (triggered care areas to indicate whether to care plan) dated 9/26/2024, revealed vision, communication, ADLs, Urinary Incontinence, Falls, Nutrition, and Pressure Ulcer was triggered and a decision to care plan was marked. Review of the Initial Wound Evaluation and Management Summary dated 9/28/2024, for Resident #56 revealed Unstageable Deep Tissue Injury (DTI - tissue damage when pressure compromises blood flow to underlying tissue) measuring 2.5 in (inches) length by 1.5 in width and depth not measurable with dressing treatment plan for house barrier cream apply every shift for 7 days. Continued review revealed the plan of care was discussed with patient, nursing staff member and the DON. Review of the Wound Evaluation and Management Summary dated 10/25/2024 for Resident #56 revealed Unstageable DTI measuring 0.7 in length, 0.6 cm in width, and depth not measurable with dressing treatment plan house barrier cream for 7 days. Review of Resident #56's Comprehensive care plan revealed a focus for falls dated 11/14/2024, and a focus for nutrition dated 1/22/2025. No care plans per the CAA Summary for vision, communication, ADLs, Urinary Incontinence, or risk for pressure ulcers. Review of Resident #56's Order Review History Report dated 2/5/2025-3/5/2025 revealed an order for Duloxetine HCL (Hydrocholoride) (Antidepressant) oral capsule delayed release sprinkle 60 mg give 1 capsule by mouth one time a day for depression and Tramadol HCL (pain medication) oral tablet 50 mg give 1 tablet by mouth every 12 hours as needed for pain. Review of Resident #56's Order Review History Report dated 2/5/2025-3/5/2025 revealed the use of Gabapentin (medication given for pain) 100 mg every 8 hours for neuropathic pain, and Lantus Solostar subcutaneous solution (Insulin) 100 unit/ML (milliliters) inject 15 units one time a day related to Diabetes Mellitus. Review of the Comprehensive care plan revealed no care focus for pain, Diabetes, or pressure ulcers. During an interview on 3/05/25 at 8:41 AM, the Registered Dietician (RD) was asked if she was aware of Resident #56's pressure ulcer. RD reviewed Resident #56's electronic chart and stated, .I would be reviewing her for the DTI which started on 2/21/2025 as MASD (Moisture Associated Skin Damage) and then 2/28/2025 it was DTI .I only see two focuses fall and nutrition on her care plan . During a telephone interview on at 3/5/2025 at 11:15 AM Regional Registered Nurse (RN) stated, .I am a regional consultant for the facility, Yes I schedule MDS tracking for them, Care plan focuses I see [for Named Resident #56] are focus for fall history, nutrition and hydration status those are the only care plans that I see, I would expect the pressure injury to be on the care plan. The CAA review for the 9/13/2024 MDS full assessment noted to proceed to care plan for visual, communication, functional abilities, urinary incontinence, pressure ulcer, and psychotropic drug use was marked to go to the care plan. They did not complete care plans per the CAA summary review . 4. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease, Dementia, Hyperlipidemia, and Hypothyroidism. Review of Resident #57's Discharge Summary from Hospital #1 dated 12/2/2024, revealed, General Information .12/2 [12/2/2024] return to LTC [Long Term Care, hospice/palliative care to follow . Review of the MDS dated [DATE], revealed Resident #57 had a BIMS score of 0 and resident was unable to complete BIMS. Continued review revealed signs and symptoms of delirium were inattention and disorganized thinking. Resident #57 received an antipsychotic over the last 7 days and received hospice care during the assessment reference period. Review of Resident #57's Order Review History Report dated 2/5/2025-3/5/2025 revealed resident #57 was receiving Duloxetine HCL [Hydrochloride) oral capsule 60 mg by mouth one time a day for Depression, Tramadol HCL oral tablet 50 mg by mouth every 12 hours as needed for pain and Gabapentin oral capsule 100 mg by mouth every 8 hours for Neuropathic pain. Further review of the orders revealed no order for hospice care. Review of the care plan for Resident #57 revealed a focus for risk for elopement and wanders initiated on 9/27/2024, a focus for altered nutritional/hydration status initiated on 10/2/2024, and focus for mood problem displayed as agitation, anxiety due to Dementia; episodes of swinging upper extremities at staff during increased periods of agitation. The care plan did not reflect a focus for hospice or use of antipsychotics. During a telephone interview on at 3/5/2025 at 11:15 AM, Regional RN was asked to review Resident #57's comprehensive care plan. Regional RN stated, .I do not see a focus for hospice care on the care plan. If a resident is experiencing pain, receiving pain medications or taking an antipsychotic this should be care planned. [Named Resident #57] is receiving Ativan (antianxiety) and Seroquel (antipsychotic) and I do not see a pain care plan or a focus for the use of Antipsychotic medications . 5. Review of the medical record revealed Resident #220 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Fracture of First Lumbar Vertebrae, Unsteadiness on feet, Asthma, and Type 2 Diabetes Mellitus. Review of the Comprehensive Care Plan dated 2/13/2025, revealed one focus for altered nutritional/hydration status related to Diabetes Mellitus, Gastroesophageal Reflux Disorder, and Chronic Kidney Disease. Continued review of the care plan revealed no further care plan focus for Resident #220. Review of the Admission MDS dated [DATE], revealed Resident #220 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #220's CAA Summary dated 3/4/2025 revealed Functional Abilities, Urinary Incontinence, Pressure Ulcer, and Pain was triggered and a decision to care plan was marked. During a telephone interview on at 3/5/2025 at 11:15 AM, Regional RN stated, the facility should be going by the CAA Summary and proceed to care plan per the assessment. 48285 49311

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 21 sampled residents (Resident #215) had clean and groomed fingernails. The findings include: 1. Review of the facility policy titled, Care of Fingernails/Toenails, dated 10/2024 revealed, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . 2. Review of the medical record revealed Resident #215 was admitted to the facility on [DATE], with diagnoses which included Wedge Compression Fracture of T7 - T8 (break in the vertebrae located at the 7th and 8th thoracic level of the spine), Wedge Compression Fracture of T11-T12 (break in the vertebrae located at the 11th and 12th thoracic level of the spine), Acute Respiratory Failure, Unspecified Cirrhosis of Liver, and Chronic Systolic Congestive Heart Failure. Review of Resident #215's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairments. Continued review revealed Resident #215 was dependent for toileting, shower/bathe, dressing, and personal hygiene. Review of Resident #215's bathing task from 2/19/2025-3/3/2025 revealed she received a shower on 2/21/2025 and 2/28/2025. Continued review revealed Resident #215 received a bed bath on 2/24/2025, 2/26/2025, 3/1/2025, and 3/2/2025. Observation and interview on 3/3/2025 at 10:56 AM in Resident #215's room revealed the resident had dried brown debris under her long unkept fingernails on both hands, she stated, I think I had a shower last Friday. Observation and interview on 3/3/2025 at 2:00 PM in Resident #215's room revealed the resident continued to have dried brown debris under her long unkept fingernails on both hands. Resident #215 stated, .I don't think I got a bath yesterday . Observation and interview on 3/4/2025 at 8:15 AM revealed Resident #215 eating her breakfast. Resident #215's fingernails continued to have dried debris under her long unkept fingernails. The Director of Nursing (DON) was asked to come into Resident #215's room on 3/4/2025 at 8:22 AM, to observe the resident's fingernails. The DON confirmed (Resident 215's) fingernails were long and filled with brown debris on both hands and stated, I will get this took care of now.

Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a comprehensive resident admission assessment within 14 calendar days after admission for 1 of 21 residents (Resident #215) sampled residents reviewed. The findings include: 1.Review of the RAI Manual Version 3.0 dated 10/2023, revealed, .For the Admission assessment, the MDS [Minimum Data Set] Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600) . For the Admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600) . 2. Review of the medical record revealed Resident #215 was admitted to the facility on [DATE], with diagnoses which included Wedge Compression Fracture of T7 - T8 (break in the vertebrae located at the 7th and 8th thoracic level of the spine), Wedge Compression Fracture of T11-T12 (break in the vertebrae located at the 11th and 12th thoracic level of the spine), Acute Respiratory Failure, Unspecified Cirrhosis of Liver, and Chronic Systolic Congestive Heart Failure. Review of the Admission MDS assessment for Resident #215 revealed a completion date of 3/4/2025, 19 days after the resident was admitted to the facility. During a telephone interview on 3/5/2025 at 11:15 AM, Regional Registered Nurse (RN) stated, .since end of January [2025] the facility has been without an MDS coordinator, I just oversee that they are setting the appropriate assessments and making sure their assessments are completed . During a telephone interview on 3/6/2025 at 7:56 AM, Regional RN was asked when an admission MDS should be completed, and she stated within 14 days of admission. Regional RN was asked to review Resident #215's MDS with completion date of 3/4/2025, and asked if the MDS was completed timely. Regional RN stated, No, it was not.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a significant change assessment for 1 resident (Resident #57) of 21 residents reviewed. The findings include: 1.Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2023 revealed .Guidelines to Assist in Deciding If a Change Is Significant or Not .When a .Resident enrolls in a hospice program .must be within 14 days from the effective date of the hospice election . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Alzheimer's Disease, Dementia, Hyperlipidemia, and Hypothyroidism. Review of Resident #57's Discharge Summary from Hospital #1 dated 12/2/2024, revealed, General Information .12/2 [12/2/2024] return to LTC [Long Term Care, hospice/palliative care to follow . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 0 and resident was unable to complete BIMS. Continued review revealed Resident #57 received hospice care during the assessment reference period. During a telephone interview on at 3/5/2025 at 11:15 AM, Regional Registered Nurse (RN) stated .I would expect a significant change MDS to be completed within 14 days after the determination to start hospice and if the resident decides to change hospice companies. I do not see a significant change was completed for [Named Resident #57] .

Based on policy review, medical record review and interview, the facility failed to have a physician's order for a resident's dialysis treatments, failed to assess and monitor the dialysis site for a thrill (palpable vibration felt over a vessel), and infection, failed to weigh or get vital signs, and failed to have an accurate individualized care plan for 1 of 1 (Resident #48) sampled residents for dialysis. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans ., dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's .needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated with identified problems .The Care Planning/Interdisciplinary is responsible for the periodic review and updating of care plans .When there has been a significant change in the resident's condition .At least quarterly . Review of the facility policy titled, Using the Care Plan ., dated 10/2024, revealed .The care plan shall be used in developing the resident's daily care routines and will .Changes of Condition should be reported .care plans update accordingly .Changes in the resident's condition will be reported . Review of the facility policy titled, Dialysis, Care for a Resident ., dated 9/2023, revealed .Obtain orders for dialysis to be provided at a certified dialysis center .The care plan will reflect the resident's needs related to .dialysis care .Pre and Post Dialysis Documentation .Prior to dialysis, provide communication to include .New labs and results .Any changes in diet, intake or resistance to care .any concerns with access site .upon return from dialysis, document .Post weight .bleeding at site . 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, End stage Renal Disease, Chronic Pain Syndrome and Diabetes. Review of the care plan dated 11/22/2024, revealed Resident #48 receives dialysis 3 times A week (peritoneal) [treatment for kidney failure] r/t [related to] End Stage Renal Disease .Left Above Knee Amputation .For peritoneal dialysis, administer solute as directed by Provider/Dialysis Center . The care plan indicated that Resident #48 received peritoneal dialysis. The Resident actually received hemodialysis. There is no documentation that Resident #48 goes to dialysis outside the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which revealed Resident #48 was cognitively intact, special procedure included Dialysis, surgical wound and dressing to feet, and medications included antipsychotics, antibiotics, and opioids. Review of the Physician's Orders dated March 2025 revealed there was no orders for hemodialysis, the location of the dialysis fistula, monitoring the fistula for patency, or a diet for Resident #48. During an interview on 3/5/2025 at 10:52 AM, Licensed Practical Nurse (LPN) N, stated that they don't get weights before or after dialysis, there is no communication with the dialysis clinic and vital signs are not gotten when Resident #48 returns from clinic. During an interview on 3/5/2025 at 11:01 AM, the Director of Nursing and Unit Manager confirmed there should be orders for hemodialysis, monitoring the fistula for patency and a renal diet. During an interview on 3/5/2025 at 3:06 PM, the Senior Director of Clinical Reimbursement confirmed the care plan is not accurate.

Based on policy review, medical record review, observation, and interviews the facility failed to honor food preferences for 1 of 24 (Resident #35) residents. The findings include: 1. Review of the facility policy titled, Resident Food Preferences . dated 10/2024, revealed .Nutritional assessments will include an evaluation of individual food preferences. Residents receive food prepared in a form designed to meet individual needs, including preferences . 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity, Muscle Weakness, Bariatric Surgery Status, and Gastro-Esophageal Reflux Disease. Review of Progress Note dated 10/15/2024, revealed . Continue to honor food preferences and encourage fluid restriction compliance Review of the care plan dated 12/13/2024, revealed .at risk for impaired nutrition .Honor food preferences and update PRN [as needed] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. During an interview conducted on 3/3/2025 at 12:00 PM, Resident #35 states, .I don't like gravy, but they always give it to me anyway . Observation of the resident's lunch tray on 3/3/2025 at 1:16 PM, revealed gravy covering the entire piece of meat. Meal card on tray stated, .Dislikes .gravy .Tray Instructions .No .Gravy . During an interview conducted on 3/5/2025, at 8:48 AM, the Registered Dietician (RD) stated, The staff should be following her [Resident #35] choices .

Based on policy review, medical record review, observation, and interview, the facility failed to follow Physician orders related to parameters for the use of as needed (PRN) pain medication for 1 of 5 sampled residents (Resident #44) reviewed for unnecessary medications; and related to Percutaneous Endoscopic Gastrostomy (PEG) medication administration for 1 of 6 sampled residents (Resident #3) reviewed for medication administration, and failed to collaborate care with Hospice Services for 1 of 3 sampled residents (Resident #515) reviewed for Hospice. The findings: 1. Review of the facility policy titled, General Dose Preparation and Medication Administration ., dated 2/2024, revealed .Prior to preparing or administering medications .Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record . Review of the facility policy titled, Hospice Program ., dated 10/2024, revealed .Obtain a physician's order for Hospice services to include diagnosis .that match the hospice information on the certification of terminal illness .Obtain the physician certification or re-certification for Hospice services .Collaboration and coordination of hospice care .Ensure the appropriate documentation is readily available .A nursing progress note stating hospice saw the resident and notes to follow .If the hospice does not document in PCC [Point Click Care] .scan and upload hospice documentation to the resident's electronic medical record .to include .most recent Hospice plan of care .election form .certification for terminal illness .Names and contact information of hospice personnel involved .Visit notes from all hospice disciplines . Review of the Facility's policy titled, Administering Medications Through an Enteral Tube ., dated 12/2021, revealed, .Aspirate small amount of stomach contents .If there is more than 100 ml [milliliter] of stomach content, withhold medication and notify the physician . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Radiculopathy (pinched nerve). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #44 was cognitively intact. Review of the Physician's orders dated 12/4/2024, revealed . oxycodone .10 MG [milligrams] .Give 10 mg by mouth every 4 hours as needed for breakthrough Pain Between 7-10 [with 10 being the worst pain] on pain scale discontinued 1/31/2025 . Review of the December 2024 Medication Administration Record (MAR) revealed oxycodone 10 mg was administered on 12/1/2024, 12/3/2024, 12/5/2024, 12/6/2024, 12/10/2024, 12/19/2024, 12/24/2024, and 12/25/2024 for pain rated below 7. Review of the January 2025 MAR revealed oxycodone 10 MG was administered on 1/5/2025, 1/9/2025, 1/24/2025, and 1/30/2025 for pain rated below 7. Review of the Physician's orders dated 1/31/2025, revealed .oxyCODONE .Oral Capsule 5 MG .Give 1 capsule by mouth every 6 hours as needed for breakthrough pain level 7-10 . Review of the February 2025 MAR revealed oxycodone 5 MG was administered on 1/1/2025, 1/15/2025, 1/18/2025, 1/19/2025, 1/20/2025, 1/21/2025, 1/22/2025, 1/23/2025, 1/25/2025, 1/27/2025, and 1/28/2025 for pain rated less than 7. Review of the March 2025 MAR revealed oxycodone 5 MG was administered on the following dates for pain rated less than 7 on 3/1/2025 and 3/2/2025. During an interview on 3/5/2025 at 10:02 AM, the Director of Nursing (DON) was asked if the Physician prescribes a medication with parameters should the physician's orders be followed. The DON replied, Yes, absolutely. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Heart Failure, and Gastrostomy. Review of the Physician's orders dated 8/12/2023, revealed, .Enteral Feed . two times a day for Feeding Check residual prior to feeding/meds. If there is more than 100 ml of stomach content, withhold feeding/medication and notify the physician . Review of the Care Plan dated 8/14/2023, revealed .at risk for fluid balance fluctuation, alteration in nutrition and weight loss Date initiated: 04/30/2024 .Administer medication as ordered . Check residual prior to feeding/meds [medications]. If there is more than 100 ml [milliliters] of stomach content, withhold feeding/medication and notify the physician. Date Initiated: 05/24/2024 . Review of the annual MDS dated [DATE], revealed the BIMS score was unable to be assessed due to severe cognitive impairment. Resident #3 was assessed for the use of a feeding tube. Review of the Physician's orders dated 8/25/2024, revealed, . levetiracetam [a medication used to treat epilepsy] Oral Solution 100 MG /ML Give 10 ml via [by way of] PEG [a feeding tube in the stomach inserted through the abdominal wall] -Tube three times a day for seizures . Observation during medication administration on the [NAME] Hall on 3/5/25 at 1:59 PM, revealed Licensed Practical Nurse (LPN) N, failed to aspirate stomach contents to verify residual prior to administering Resident #3's medication per peg tube. During an interview on 3/5/2025 at 5:24 PM, the Director of Nursing (DON) confirmed aspiration of stomach contents should have been performed to verify residual prior to medication administration. 4. Review of the medical record revealed Resident #515 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, and Anxiety. Review of the care plan dated 5/18/2023, revealed Resident was receiving hospice services from (Named Hospice) secondary to terminal prognosis. Review of the physician orders dated 7/28/2023 revealed Resident #515 was admitted to Hospice. Review of the MDS assessment dated [DATE], revealed a BIMS score was unable to be completed. Resident #515 was severely impaired for daily decision making. Special procedures and programs included Hospice Care. Review of the hospice documentation scanned into Resident #515's record revealed the last hospice document was from 3/13/2024. During an interview on 3/5/2025 at 2:15 PM, LPN R was asked if there were any current Hospice documents. She stated, Everything has been scanned, and we haven't gotten any documents from them in a while . She was unable to locate any documents to show collaboration with the hospice agency or the required documentation per the facility policy. 51365

Based on Administrator, Director of Nursing, and Nurse Supervisor job descriptions, Emergency Management System's Computer-Aided Dispatch Report (CAD), policy review, medical record review, and interview, the facility failed to ensure staff had the competencies and skill sets to communicate with each other after a resident eloped, to perform a head count of all residents in the facility after the elopement, to perform a complete assessment of the resident after the elopement, to provide close supervision of the resident after the elopement, to monitor the resident's elopement behaviors after the elopement, to consistently monitor wanderguards (ankle or wrist band tracking system that automatically locks and alarms the doors when the device is near the exit door) for placement and function following the elopement, to timely notify the family and the Medical Director after the elopement, and to recognize and respond to a door alarm when it sounded. This resulted in Immediate Jeopardy (IJ) for Resident #1 when he exited the facility through the front door in his wheelchair, crossed the front parking lot, and stopped in a lower parking lot, 38 feet from the facility's front door, near a heavily traveled street. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on 9/3/2020 at 4:42 PM, in the DON office. The facility was cited Immediate Jeopardy at F-726, at a scope and severity of K. The IJ was effective from 8/16/2020 through 9/3/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/4/2020 at 12:00 PM and was validated onsite by the surveyors on 9/4/2020 by review of policies related to active exit-seeking behaviors, assessments, in-service training records, and staff interviews. The findings include: Review of the Administrator job description revised 8/2018, showed, .JOB SUMMARY .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home .Manages staff at the facility .Supervise and provide guidance and support to department heads .Meet standard staffing goals .Recruit, employ and ensure adequate training of personnel in the facility .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Determine staffing needs of the facility .Recruitment and hiring of personnel .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the Director of Nursing job description revised 8/2018, showed, .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education for all nursing employees .Develops and maintains nursing service objectives, standards of nursing practice and policy and procedure manuals .Evaluates resident records to assure accuracy, care plans are current and complete and residents receiving optimal care .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Attend and participate in orientation programs, ongoing training and educational classes . Review of the Nurse Supervisor job description dated 2003, showed, .Ensure that a sufficient number of licensed practical and/or registered nurses are available for your tour of duty to ensure that quality care is maintained .Ensure that a sufficient number of certified nursing assistants are available for your tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Develop work assignments .Delegate to each Charge Nurse the administrative authority, responsibility, and accountability necessary to perform his/her assigned duties .Meet with your shift on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services . Review the facility's policy titled, Amber Alert Drills, dated 6/15/2020, documented, .Resident Head Count . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Wandering and Elopement Evaluation dated 5/27/2020, showed Resident #1 had severe cognitive impairment, had a history of [REDACTED]. Review of a CAD Report dated 8/16/2020 at 4:43 PM, showed the Police Department received a 911 phone call from a passing motorist that a patient was in a wheelchair sitting toward the bottom of the parking lot. At this time the facility was unaware the resident was missing from the facility. Review of a computerized Nurse's Note dated 8/17/2020 at 1:18 PM, showed a late entry for 8/16/2020 and documented Resident #1 was sitting in a wheelchair in the parking lot wearing a wanderguard and the staff assisted the resident back in the building. Licensed Practical Nurse (LPN) #3 documented this late entry on 8/17/2020 but was unaware the resident was out of the building on 8/16/2020, even though she was the nurse responsible for Resident #1's care. During an interview on 8/28/2020 at 10:45 AM, the Human Resources stated, .(Therapy Program Manager) looks at me and tells me to call .(Administrator) .and she started running. I looked up and saw (Resident #1). He was at the bottom parking lot .He was in the parking spaces. He was 15 (to) 20 feet away from the street .It is a main thoroughfare .by the time I got to him, she was pushing him back to the building .We noticed a police car was driving through our parking lot .Staff did not realize he was gone . During a telephone interview on 8/28/2020 at 2:32 PM, LPN #3 was asked about the day of the elopement. She stated, I was running from hall to hall, we were having residents with Sats (oxygen levels) dropping .I had all North Hall and half of another hall. I had one (a resident) that was sick, she was sent out .I kept taking care of her and other residents, I had 32 residents . She stated she was in a resident room on West Hall and could not hear the alarm. During an interview on 8/28/2020 at 5:27 PM, the Administrator confirmed he was not able to provide any documentation a head count was done after the elopement. During a telephone interview on 8/28/2020 at 5:49 PM, CNA #4 confirmed she worked in the facility the day of the elopement. She stated she wasn't told to do a head count. Review of the medical record, showed there was no documentation that an assessment or vital signs were performed for Resident #1 after he eloped, there was no documentation he was closely supervised by nursing staff after he eloped and Resident #1's wanderguard and wandering behaviors were not monitored consistently after he eloped. Observation in the resident's room on 8/26/2020 at 5:10 PM, 8/28/2020 at 12:42 PM, 8/29/2020 at 3:55 PM, 8/30/2020 at 10:40 AM and 11:40 AM, and on 9/1/2020 at 9:28 AM, showed Resident #1 had a wanderguard intact to his left ankle. Review of Resident #1's August 2020 Treatment Administration Record (TAR), showed wanderguard function and placement monitoring was not documented as performed on the night shift for 8/ 0, 8/13/2020, 8/15/2020, 8/16/2020, 8/18/2020, 8/22/2020, 8/26/2020, and 8/28/2020. Behavior monitoring was not initiated on the TAR until 8/19/2020, after the elopement, when Regional Nurse Consultant #1 suggested staff document behaviors on the TAR. During a telephone interview on 8/28/2020 at 2:34 PM, LPN #4 stated, .I was not asked to do an assessment. He was not my patient. I just stopped to get his vital signs. I did not know he had eloped . LPN #4 was asked if she was in-serviced on wanderguard monitoring. She stated, I have no idea. LPN #4 was asked where she documented the vital signs. She stated, I gave them to the nurse manager and (named Human Resources) . During an interview on 8/28/2020 at 3:48 PM, Certified Nursing Assistant (CNA) #3 confirmed she was the CNA responsible for Resident #1 the day he eloped. She stated, .I did not know he had gotten out of the building. I was not aware the alarm set off .Then I saw (named Therapy Program Manager) and (named Human Resources) bring him back in the building. I asked (named Therapy Program Manager) what happened. She told me it was not my business and it's not to be talked about. (named Human Resources) started to tell me and (named Therapy Program Manager) stopped her. They did not have me do anything with him. I tried to ask the nurse and she pushed me off .I did not receive any training prior to the incident. The wanderguards don't get checked like they are supposed to .I was never trained to check the placement. I was never told to check the wanderguards. CNA #3 was asked if she did a head count. She stated, .I wasn't told to do one . CNA #3 stated she was very frustrated with the situation in the facility, and had turned in her resignation 8/28/2020. During an interview on 8/28/2020 at 6:35 PM, the Therapy Program Manager confirmed she discovered Resident #1 had left the building and she found him in the lower parking lot and brought him back into the building. The Therapy Program Manager was asked why she told CNA #3 to mind her own business and why she did not inform CNA #3 her resident had eloped. She stated it was not her job to alert everyone, and stated, .I made aware of who needed to know . She stated, .I don't remember telling anyone to do a head count .no one handed me any vital signs .I am not clinical .They should have turned to their clinical staff . The Therapy Program Manager was asked if she reported the elopement to the nurse in charge of Resident #1. She stated, .I can't say who I reported it to in the facility . The Therapy Program Manager was not aware of reporting incidents of elopement to the nursing staff. During an interview on 8/29/2020 at 2:54 PM, LPN #4 stated she did not do one on one supervision of Resident #1 after the elopement. She was asked if she did a head count after the elopement. She stated, No, I did not. She stated, I had no idea of what was going on. Review of the Social Worker's Progress Notes dated 8/18/2020, showed the family was not notified about the elopement until 2 days after the elopement. Review of the Physician's Progress notes dated 8/24/2020, showed the Medical Director was not notified about the elopement until 8/24/2020, 8 days after the elopement. During an interview on 8/29/2020 at 1:02 PM, the Unit Manager confirmed staff should notify the family and physician, they should attempt three times, and document attempts to notify. Observation at the Nurse's Station on 8/30/2020 at 11:48 AM, showed a door alarm sounding. LPN #1 and LPN #2 were sitting in the nurse's station talking and did not get up to check the doors when the alarm sounded. During an interview on 8/30/2020 at 12:00 PM, LPN #1 and LPN #2 confirmed they did not know the alarm was a door alarm. At that time, the Administrator walked up to the nurse's station and confirmed it was the door alarm sounding. During an interview on 8/31/2020 at 2:16 PM, the Medical Director was asked what nurses should do when they find a resident had eloped. The Medical Director stated, .inform the Supervisor, the Physician, the Administrator .look for the patient as soon as they know .they are like a child, run to the road, they have to do anything to prevent any accident .check vitals .temperature change .pulse increase, signs of dehydration .Head to toe check to see he didn't fall, no injury .system assessment, lungs, cardiovascular, skin, take a lab test if needed. This should be the standard. Staff need to inform the MD (Medical Doctor) of the assessment findings to see if they can be managed in-house or need other treatment. They need to be monitored .often .every 15 minutes for behavior, vital signs. They are more high risk than other residents . Refer to F-656, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. On 8/29/2020, a nursing order had been added to the resident's record for licensed nurses to monitor residents for exit seeking behavior every shift. The surveyors reviewed residents' medical records for behavior monitoring documentation. 2. On 8/29/2020 through 9/1/2020, nursing staff was re-educated to the Elopement policy. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors interviewed staff and reviewed the in-service notes and sign in sheets. 3. On 8/29/2020 through 9/1/2020, staff were re-educated on completing a headcount immediately. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors interviewed staff and reviewed the in-service notes and sign in sheets. 4. On 8/29/2020 through 9/1/2020, nursing staff was re-educated on documentation expectations regarding behavior monitoring related to exit seeking behavior. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors interviewed staff and reviewed the in-service notes and sign in sheets. 5. On 8/29/2020 through 9/1/2020, staff were re-educated on the documentation for wanderguard monitoring. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors interviewed staff on all shifts and reviewed the in-service notes and sign in sheets. 6. On 8/29/2020 through 9/1/2020, staff were re-educated on the policy and procedures regarding resident elopement and if the resident leaves the premises or a safe area without authorization. Staff were educated on the steps to take in the event of a resident elopement. Licensed nursing staff were re-educated to the Elopement policy regarding the steps to be taken once the resident is returned to the facility, which included the following: i. Examine the resident for injuries; ii. Contact the Attending Physician and report findings and conditions of the resident; iii. Notify the resident's legal representative (sponsor); iv. Notify the Administrator and Director of Nursing; v. Notify search teams that the resident has been located; vi. Complete and file an incident report; and vii. Document relevant information in the resident's medical record. Staff were re-educated on completing a head count immediately. Nursing staff were re-educated on documentation expectations regarding behavior monitoring for elopement risk residents. Staff were re-educated on the documentation for wanderguard monitoring. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors reviewed the in-service records and interviewed staff on all shifts. 7. Wander guard documentation will be reviewed daily times (x) 7, weekly x 4, monthly x 3 for completeness by the DON/Designee. The surveyors reviewed the audit forms and interviewed the DON. 8. Point of Care documentation will be reviewed daily x 7, weekly x 4 and monthly x 3 by the DON/Designee. The surveyors interviewed the DON. 9. Residents with moderate to high risk for wandering or elopement behavior will be reviewed in Patient at Risk weekly meetings and as needed based upon new behaviors, by the Interdisciplinary Team (IDT) based on the new behavior. The surveyors interviewed members of the IDT. Noncompliance of F-726 continues at a scope and severity of E for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, medical record review, observation, and interview, the facility Administration failed to provide oversight to ensure staff communication after the elopement, ensure head counts were performed after the elopement, ensure a resident assessment was performed following the elopement, ensure close supervision of a resident after the elopement, ensure a resident's wandering behaviors were monitored after an elopement, ensure wanderguards (ankle or wrist band tracking system that automatically locks and alarms the doors when the device is near the exit door) were being consistently monitored, ensure timely notification of the elopement to the family and Medical Director after the elopement, ensure staff were recognizing and responding to door alarms, ensure a complete, timely, and thorough investigation of the elopement, ensure sufficient and competent staffing to provide care for the residents, and ensure consistent administrative leadership when a vulnerable resident eloped from the facility. The Administrator's failure to provide a safe environment placed 1 of 5 sampled residents (Resident #1) reviewed for elopement and wandering behaviors resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident with a history of wandering and elopement attempts was found unsupervised in the lower parking lot of the facility. Resident #1 propelled himself in a wheelchair, and exited through the front door into the parking lot. Resident #1 was found 201 feet from the front door in the lower parking lot, 38 feet from a heavily traveled street in front of the facility. This resulted in an IJ for Resident #1. The facility was cited a deficiency at F-835 on 8/29/2019 as a result of the elopement of a resident into the street in front of the facility. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy for F-835 on 9/3/2020 at 4:42 PM, in the DON office. The facility was cited Immediate Jeopardy at F-610, F-656, F-689, F-726, F-835, and F-867. The facility was cited at F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 8/16/2020 through 9/3/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/4/2020 at 12:00 PM, and was validated onsite by the surveyors on 9/4/2020 by review of audits, in-service training records, observations, and staff interviews. The findings include: The facility's Administrator Job Description revised 8/2018, showed, .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home .Manages staff at the facility .Supervise and provide guidance and support to department heads .Meet standard staffing goals .Recruit, employ and ensure adequate training of personnel in the facility .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Determine staffing needs of the facility .Recruitment and hiring of personnel .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . The facility's Director of Nursing Job Description revised 8/2018, showed, .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Responsible for supervising direction of resident care . Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur .immediately report any time a resident is observed leaving campus . Review the facility's policy titled, Amber Alert Drills, dated 6/15/2020, documented, .Resident Head Count . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Wandering and Elopement Evaluation dated 5/27/2020, showed Resident #1 had severe cognitive impairment, had a history of [REDACTED]. Review of a Emergency Management System's Computer-Aided Dispatch Report (CAD) dated 8/16/2020 at 4:43 PM, showed the Police Department received a 911 phone call from a passing motorist that a patient was in a wheelchair sitting toward the bottom of the parking lot. At this time the facility was unaware the resident was missing from the facility. Review of a computerized Nurse's Note dated 8/17/2020 at 1:18 PM, showed a late entry for 8/16/2020 and documented Resident #1 was sitting in a wheelchair in the parking lot wearing a wanderguard and the staff assisted the resident back in the building. Licensed Practical Nurse (LPN) #3 documented this late entry on 8/17/2020 but was unaware the resident was out of the building on 8/16/2020, even though she was the nurse responsible for Resident #1's care. During an interview on 8/28/2020 at 10:45 AM, the Human Resources stated, .(Resident #1) was at the bottom parking lot .He was in the parking spaces. He was 15 (to) 20 feet away from the street .It is a main thoroughfare .Staff did not realize he was gone . During an interview conducted on 8/28/2020 at 5:27 PM, the Administrator confirmed there was not a head count done after the elopement until the midnight census on 8/17/2020 at 1:45 AM. The Administrator stated he could not confirm or deny the head count was done after Resident #1 eloped. The Administrator was asked if 1:45 AM, would have been an appropriate time to do a head count. The Administrator stated, No . During a telephone interview on 8/28/2020 at 5:49 PM, Certified Nursing Assistant (CNA) #4 confirmed she worked in the facility the day of the elopement. She stated she wasn't told to do a head count. Review of the medical record showed, there was no documentation that an assessment or vital signs were performed for Resident #1 after he eloped, there was no documentation he was closely supervised by nursing staff after he eloped, and Resident #1's wanderguard and wandering behaviors were not monitored consistently after he eloped. Observation in the resident's room on 8/26/2020 at 5:10 PM, 8/28/2020 at 12:42 PM, 8/29/2020 at 3:55 PM, 8/30/2020 at 10:40 AM and 11:40 AM, and on 9/1/2020 at 9:28 AM, showed Resident #1 had a wanderguard intact to his left ankle. Review of Resident #1's August 2020 Treatment Administration Record (TAR), showed wanderguard function and placement monitoring was not documented as performed on the night shift for 8/ 0, 8/13/2020, 8/15/2020, 8/16/2020, 8/18/2020, 8/22/2020, 8/26/2020, and 8/28/2020. Behavior monitoring was not initiated on the TAR until 8/19/2020, after the elopement, when Regional Nurse Consultant #1 suggested staff document behaviors on the TAR. During a telephone interview on 8/28/2020 at 2:34 PM, LPN #4 stated, .I was not asked to do an assessment. He was not my patient. I just stopped to get his vital signs. I did not know he had eloped . LPN #4 was asked if she was in-serviced on wanderguard monitoring. She stated, I have no idea. LPN #4 was asked where she documented the vital signs. She stated, I gave them to the nurse manager and (named Human Resources) . During an interview on 8/28/2020 at 3:48 PM, CNA #3 confirmed she was the CNA responsible for Resident #1 the day he eloped. She stated, .I did not know he had gotten out of the building. I was not aware the alarm set off .Then I saw (named Therapy Program Manager) and (named Human Resources) bring him back in the building. I asked (named Therapy Program Manager) what happened. She told me it was not my business and it's not to be talked about. (named Human Resources) started to tell me and (named Therapy Program Manager) stopped her. They did not have me do anything with him. I tried to ask the nurse and she pushed me off .I did not receive any training prior to the incident. The wanderguards don't get checked like they are supposed to .I was never trained to check the placement. I was never told to check the wanderguards. CNA #3 was asked if she did a head count. She stated, .I wasn't told to do one . During an interview on 8/28/2020 at 6:35 PM, the Therapy Program Manager confirmed she discovered Resident #1 had left the building and she found him in the lower parking lot and brought him back into the building. The Therapy Program Manager was asked why she told CNA #3 to mind her own business and why she did not inform CNA #3 her resident had eloped. She stated it was not her job to alert everyone, and stated, .I made aware of who needed to know . She stated, .I don't remember telling anyone to do a head count .no one handed me any vital signs .I am not clinical .They should have turned to their clinical staff . The Therapy Program Manager was asked if she reported the elopement to the nurse in charge of Resident #1. She stated, .I can't say who I reported it to in the facility . The Therapy Program Manager was not aware of reporting incidents of elopement to the nursing staff. During an interview on 8/29/2020 at 2:54 PM, LPN #4 stated she did not do one on one supervision of Resident #1 after the elopement. She was asked if she did a head count after the elopement. She stated, No, I did not. She stated, I had no idea of what was going on. Review of the Social Worker's Progress Notes dated 8/18/2020, showed the family was not notified about the elopement until 2 days after the elopement. Review of the Physician's Progress notes dated 8/24/2020, showed the Medical Director was not notified about the elopement until 8/24/2020, 8 days after the elopement. During an interview on 8/29/2020 at 1:02 PM, the Unit Manager confirmed staff should notify the family and physician, they should attempt three times, and document attempts to notify. Observation at the Nurse's Station on 8/30/2020 at 11:48 AM, showed a door alarm sounding. LPN #1 and LPN #2 were sitting in the Nurse's Station talking and did not get up to check the doors when the alarm sounded. During an interview on 8/30/2020 at 12:00 PM, LPN #1 and LPN #2 confirmed they did not know the alarm was a door alarm. At that time, the Administrator walked up to the nurse's station and confirmed it was the door alarm sounding. Review of the facility's investigation showed the investigation did not identify why Resident #1's charge nurse was not informed of his elopement, the breakdown in communication that led to Resident #1 not receiving a full assessment after the elopement, the reason staff did not perform a head count of all residents immediately after the elopement, the reason for the delay in contacting the family and the Medical Director about the elopement, the reason wanderguard checks were not being conducted consistently, or identify staff who did not know how to monitor the wanderguards, and did not show the Medical Director's specific input for the improvement plan during the Ad Hoc QAPI meeting on 8/18/2020. Review of a Timeline of the elopement investigation, presented by the Regional Nurse Consultant did not show a date the timeline was started or completed. During an interview conducted on 8/27/2020 at 2:20 PM, the Administrator was asked for any additional information related to the facility's investigation for Resident #1's elopement on 8/16/2020. The Administrator stated, .will e-mail information . The facility failed to e-mail additional information related to the facility's investigation. The Administrator confirmed he was notified by the Therapy Program Manager of Resident #1's elopement on 8/16/2020. During a telephone interview conducted on 8/27/2020 at 2:52 PM, the Social Worker confirmed she assisted the Regional Nurse Consultant #1 with the investigation of the elopement that occurred on 8/16/2020, but was uncertain of the time. The Social Worker stated, .I went over the Policies and Procedures .(Named Regional Nurse Consultant #1) is not from Tennessee and she was not familiar with Tennessee . During a telephone interview on 8/28/2020 at 2:32 PM, LPN #3 was asked about the day of the elopement. She stated, I was running from hall to hall, we were having residents with Sats (oxygen levels) dropping .I had all North Hall and half of another hall. I had one (a resident) that was sick, she was sent out .I kept taking care of her and other residents, I had 32 residents . She stated she was in a resident room on West Hall and could not hear the alarm. During a telephone interview on 8/28/2020 at 2:38 PM, LPN #4 stated, There's not enough staff .I was doing patient care, passing trays, and passing meds (medications) . During a telephone interview on 8/28/2020 at 3:33 PM, CNA #4 stated she did not know Resident #1 had eloped until the next day. She stated, The weekend is always short staffed .We were short that Sunday (the Sunday Resident #1 eloped). During an interview on 8/29/2020 at 2:55 PM, LPN #4 stated staff never knew what was going on in the building and stated, .here's your list of techs (CNAs) and out of the list of techs, we are lucky if they all show up . During an interview on 8/31/2020 at 2:18 PM, the Medical Director confirmed there had been several interim Administrators and DONs. He confirmed the facility needed someone who was vested and stated, Leadership is the key. Telephone interview on 8/31/2020 at 7:23 PM, LPN #5 stated, .I don't think this facility holds high standards. I found it is not a good place for me. Saturday was my last day. LPN #5 was asked what specific concerns he had identified. He stated, .patients wandering . During an interview on 9/1/2020 at 10:16 AM, the Unit Manager stated, Staff were sent by agency that I wasn't made aware of . and confirmed she did not know what agency staff were in the building. During an interview on 9/2/2020 at 2:09 PM, the DON confirmed that administrative staff were responsible for identifying and monitoring staff in the building at all times, including agency staff. During an interview conducted on 9/2/2020 at 6:18 PM, the Administrator confirmed Resident #1's elopement occurred when staff thought that the alarm was activated by Resident #4, then the staff turned off the alarm, and did not go out and look, and a head count was not done. The Administrator was asked if he had identified staffing concerns. The Administrator stated, We are in crisis mode now . During an interview on 9/2/2020 at 7:33 PM, the Administrator confirmed he was not aware of staffing and agency staffing in the facility each day. During an interview on 9/2/2020 at 7:46 PM, the Regional Vice President stated, I was asked to come in and manage the building after the last elopement . The Regional Vice President was asked how many Administrators and DONs the facility has had since the last elopement. He stated 5 Administrators were interim, and the former DON left during the last elopement and they have had 4 or 5 DONs. The facility had 5 Administrators in the past 12 months. During an interview on 9/3/2020 at 1:55 PM, the DON confirmed nursing staff should have been monitoring behaviors for the residents at risk for wandering and elopement, performing more frequent monitoring after the elopement, and checking the wanderguards for placement and functioning. During an interview on 9/4/2020 at 3:03 PM, the Medical Director confirmed the Administrator needed to be aware of staffing, and there had to be a chain of command. Refer to F-610, F-656, F-689, F-726, and F-867. The Surveyor verified the Removal Plan by: 1. Administrator will provide ongoing monitoring by reviewing audit sheets for exit doors Monday through Friday. Governing body to provide Administrator monitoring by reviewing audit sheets, logs, and action plan. The surveyors reviewed audit documentation of door checks and interviewed the Administrator. 2. Walking rounds with the Administrator and Maintenance Director will occur Monday through Friday to ensure doors are locked. Weekend door checks will be completed by the manger on duty and recorded on the log sheet. The Governing body is to provide monitoring of the Administrator by reviewing audit sheets, logs, and action plan. The surveyors interviewed the Maintenance Director and reviewed the audit documentation of the door locks. 3. The Administrator will monitor the Point of Care (POC) and Treatment Administration Record (TAR) documentation for accuracy. The Governing body will provide Administrator monitoring by reviewing audit sheets, logs, and action plan. The surveyors reviewed in-services, medical records, and interviewed the Administrator. 4. Maintenance will check the alarmed door daily and document the results in the logbook Monday-Friday and the Manager on Duty will do this on Saturday and Sunday. The surveyors reviewed the Maintenance logs. 5. The Administrator will review and monitor the accuracy of the schedule with the DON daily Monday through Friday, and will review the weekend schedule prior to the end of the day on Friday. The Governing body will provide monitoring of the Administrator by review of the audit sheets. The surveyors interviewed the DON on the procedure of reviewing the schedule for accuracy. 6. On 8/30/2020, the Administrator was educated on conducting thorough and timely investigations after a resident elopes. This included a template to guide the investigation. The Governing body will provide monitoring of the Administrator by reviewing the audit sheets, logs, and action plan. The surveyors interviewed the Administrator and reviewed the template guide. 7. On 8/30/2020, staff were educated on the elopement checklist which includes what actions to take after an elopement and included monitoring a resident post elopement, head counts after a suspected or actual elopement, and assessment of the resident after an elopement. The surveyors verified the in-service documentation and interviews were conducted with staff on all shifts. 8. On 8/30/2020, staff were educated regarding documentation of monitoring residents for wandering/elopement behaviors, identifying alarms, responding to the alarms and recognizing a resident displaying exit-seeking behaviors. The surveyors reviewed the in-service records and interviewed staff on all shifts. 9. On 9/3/2020, a new Daily Schedule was created to direct staff to the appropriate assignment. The daily schedule is to be posted at the Nurse's Station and a copy will be placed in the assignment binder. The surveyors verified this through interviews with staff and in-service reviews. 10. On 9/3/2020, staff were educated on the schedule and to initial by their assignment upon arrival for their shift. The surveyors verified through staff interviews and in-service sheets. 11. On 9/3/2020, the Administrator informed the Medical Director of the additional deficiencies identified. The Medical Director confirmed he will need to monitor and follow up with the Administrator regarding staffing and Quality Assurance (QA) concerns. 12. On 9/3/2020, staff were educated regarding removing any staff that were not reporting to work by drawing a line through the name and writing the replacement staff member next to the assignment. The surveyors verified this through staff interviews and in-service sheets. 13. All staff will be educated prior to the start of their first shift in the building. This includes any staff that are currently off or on leave. The surveyors verified this through an interview with the DON. 14. Walking rounds will occur daily, Monday through Friday, by the Administrator and Maintenance Director. Round sheets will be reviewed monthly during the Quality Assurance and Performance Improvement (QAPI) meeting times (x) 2 weeks, then with monthly until the QAPI team determines that round sheet reviews are unnecessary. The surveyors reviewed the round sheets and interviewed the Administrator. 15. Monitoring of the POC/TAR documentation by the Administrator will occur Monday through Friday for 6 weeks, then weekly for 3 weeks. The surveyors interviewed the Administrator. 16. The Administrator/Designee will obtain from the agency a daily listing of agency staff that had been provided to the facility on Monday through Friday, and on Mondays will reconcile the weekend agency staff. The surveyors interviewed the Administrator regarding the process. 17. Administrator/Designee will review the prior days posted staffing schedule to ensure that the initials correspond with staff members on the shift. If the staff member did not work will validate the replacement staff member's name has been added to the daily schedule. The surveyors interviewed the Administrator. 18. The Administrator will review any elopements/potential abuse allegations and investigations and monitor for timely and thorough investigations weekly x 4 and monthly x 3. Abuse/elopement investigations will be reviewed in Quality Assurance Performance Improvement (QAPI) meeting weekly x 2 then monthly and changes will be implemented as required through the review. The surveyors interviewed the Administrator. 19. Elopement drills will be completed weekly on alternating shifts x 4 weeks, then monthly on alternating shifts. Elopement drill worksheets will be reviewed at QAPI weekly x 2 then monthly until the QAPI committee determines a review is no longer necessary. The surveyors reviewed the elopement drill worksheets, interviewed the Administrator, and observed an elopement drill. Noncompliance of F-835 continues at a scope and severity of E for the monitoring and effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on the Quality Assessment and Performance Improvement (QAPI) policy review, job description review, record review, and interview, the QAPI committee failed to ensure the facility was administered in a manner that enabled it to identify a quality care issue, and develop and implement an appropriate plan to correct identified issues for elopement in order to provide a safe environment for residents. The failure of the QAPI Committee to ensure systems and processes were in place, and systems were consistently followed by staff and Administration placed 1 of 5 sampled residents (Resident #1) reviewed for wandering/elopement behaviors in Immediate Jeopardy (IJ). Resident #1, a vulnerable resident with severe cognitive impairment, had a history of [REDACTED]. He lacked safety awareness of the current situation and wore a wanderguard. Resident #1 was found in the parking lot unsupervised, 38 feet from a heavily traveled street. The staff were unaware that the resident was out of the facility. The facility was cited a deficiency at F-867 at a J on 8/29/2019 as a result of the elopement of a resident into the street in front of the facility Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-867 on 9/3/2020 at 4:42 PM, in the DON's office. The facility was cited Immediate Jeopardy at F-610, F-656, F-689, F-726, F-835, and F-867. The facility was F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 8/16/2020 through 9/3/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/4/2020 at 12:00 PM, and was validated onsite by the surveyors on 9/4/2020 through review of Ad hoc meeting minutes, review of in-service training records, audits, and staff interviews. The findings include: Review of the facility's policy titled, Quality Assessment and Performance Improvement Committee F 867, showed, .This facility shall establish and maintain a Quality Assessment and Assurance Committee (QAPI) that oversees the identification and handling of Adverse Event: an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk there of .The committee has the full authority to oversee the implementation of the QAPI program, including .Identifying negative and positive outcomes of care and services .Establishing quality indicators and identifying pertinent standards of practice .Meeting with the owner/governing board (body) to review quality-related items .Recommended Committee Members ( .Required) .Administrator .Director of Nursing Services .Medical Director .Dietary Representative .Social Services Representatives .the committee will meet monthly at an appointed time .Special meetings may be called by the coordinator as needed to address issues that cannot be held until the next regularly scheduled meeting .The committee shall maintain minutes of all regular and special meetings that include .The date and time the committee met .The names of committee members present and absent .A summary of the reports and findings .A summary of any approaches and action plans to be implemented .Conclusions and recommendations from the committee .The time the meeting adjourned .The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care .quality issues many include .Adverse Event review including systematic identification, investigation, analysis which lead to corrective action .New or revised policies and procedures .Staffing changes .Adjustment in employment practices .The Quality Assessment and Assurance Committee will scrutinize all department reports and summarize the findings in the committee minutes .The Quality Assessment and Assurance Committee shall help various departments/committees/disciplines/individuals develop and implement .include specific time frames for implementation and follow-up .The committee shall track the progress of any active plans of correction .The committee shall advise the administration of the need for policy or procedural changes . Review of the facility's policy titled, Elopement 689, approved on 1/2020, showed, .Staff shall evaluate, investigate and report all cases of missing residents .Elopement occurs when a resident leaves the premises of a safe area without authorization .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse .When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file Accident /Incident Report .and .Document the event in the resident's medical record .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders. Examples of resident behavior requiring such actions are .Wandering not conductive to the safety of the resident or other residents in the community .New wandering behavior or attempted elopement will be .documented in the Nurses Note as to effect of interventions. Update Care Plan . Review of the facility's Administrator Job Description revised 8/2018, showed, .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home .Manages staff at the facility .Supervise and provide guidance and support to department heads .Meet standard staffing goals .Recruit, employ and ensure adequate training of personnel in the facility .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Determine staffing needs of the facility .Recruitment and hiring of personnel .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the facility's Director of Nursing Job Description revised 8/2018, showed, .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Responsible for supervising direction of resident care .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur .immediately report any time a resident is observed leaving campus . During an interview on 8/29/2020 at 1:02 PM, the Unit Manager confirmed it is the nurses' responsibility to chart the Wanderguard checks on the Treatment Administration Record (TAR). The Unit Manager was asked who tracks the TAR to ensure Wanderguard checks are being performed. She stated, We do. We have identified some problems. She was asked if the facility has put a plan in place. She stated, I would need to check. The facility did not provide the Wanderguard auditing or the corrective action plan. She confirmed the nurses should be monitoring resident behaviors. She confirmed the behavioral monitoring was not put on the TAR of residents with wandering/elopement behaviors until after Resident #1 eloped. During a telephone interview on 8/29/2020 at 2:10 PM, the Minimum Data Set (MDS) Coordinator confirmed she had identified Resident #1 was an elopement risk on 9/17/2019, and, at that time, put in place interventions to identify patterns of wandering and elopement. She was asked where the interventions were documented. She stated the Certified Nursing Assistants (CNAs) do the behavior documentation. She stated, We do periodic checks of the documentation .I have noticed missing documentation tremendously . She confirmed Behavior monitoring was not initiated on the TAR until 8/19/2020, after the elopement, when Regional Nurse Consultant #1 suggested nursing staff document behaviors on the TAR. During an interview on 8/31/2020 at 2:16 PM, the Medical Director was asked when he was notified of the elopement of Resident #1 that occurred on 8/16/2020. He stated he could not remember the date but would look at his notes. He stated he was in the facility that day, and once he was informed, he did an assessment. Review of a physician progress notes [REDACTED].The patient had an episode of elopement last week, just come to know .Discussed with Administration, Nursing Supervision and worked on action plan to prevent this happening again . Review of an undated ELOPEMENT CHECK LIST provided 8/26/2020 at 11:30 AM, by the Regional Nurse Consultant #1, showed, .Ad Hoc meeting was completed, messages left for Medical Director 8.18.20 (8/18/2020) . The Medical Director was unaware of this Ad Hoc QAPI meeting. During an interview on 9/2/2020 at 6:18 PM, the Administrator stated a QAPI meeting was held on 8/27/2020, but had no documentation of the meeting or minutes to review. During an interview on 9/2/2020 at 7:46 PM, the Regional Vice President confirmed he had informed the Administrator of the facility's history of a prior elopement on 8/20/19, when the Administrator was interviewing for the Administrator position. He stated that he .served as the Interim Administrator. The Regional Vice President was asked how many Interim Administrators the facility has had since the last elopement. The Regional Vice President stated, 5, I think. The Regional Vice President was asked how many DONs the facility had since the last elopement. The Regional Vice President stated, The old DON left during the (prior) elopement (on 8/20/2019), so 4 or 5 . He confirmed he had re-educated the Administrator on elopement and abuse the Monday following the 8/16/2020 elopement. The facility had 4 interim Administrators in the last 12 months. The present Administrator was hired on 4/1/2020 and is a full time, permanent Administrator. Refer to F-610, F-656, F-689, F-726, and F-835. The surveyors verified the Removal Plan by: 1. An Ad hoc meeting was held on 8/27/2020 with the Administrator, DON, the Unit Manager, Business Development, Therapy Program Manager, Maintenance Director, Housekeeping Director, District Housekeeping Manager, and the Medical Director (via Zoom) were in attendance. Another Ad hoc meeting was held 9/3/2020 with the Interdisciplinary team (IDT) to review the Removal Plan for Immediate Jeopardy as well as plans of action for elopement incidents. The surveyors interviewed the Administrator and DON and reviewed the meeting sign in sheets. 2. The QAPI/Interdisciplinary Team (IDT) will develop and implement appropriate plans of action to correct any identified deficient practices. The surveyors interviewed members of the IDT. 3. The QAPI/IDT will meet to identify any practice which does not comply with the facility's policies and procedures. The surveyors interviewed members of the IDT. 4. Identified concerns will have an appropriate plan of action put in place for corrections. 5. The Medical Director will be notified by the Administrator of any deficient practice identified. The surveyors interviewed the Medical Director. 6. The QAPI meeting will be scheduled on a regular basis. The Governing Body will oversee the QAPI program on a monthly basis by reviewing the QAPI minutes, and any recommendations will be implemented. The surveyors interviewed members of the QAPI team. Noncompliance of F-867 continues at a scope and severity of E for the monitoring and effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, review of the local Emergency Management System's Computer-Aided Dispatch Report (CAD), medical record review, and interview, the facility failed to ensure a thorough and timely investigation of an elopement for 1 of 5 sampled residents (Resident #1) reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) for Resident #1. Resident #1, a vulnerable resident at risk for wandering and exit seeking behavior, eloped from the facility and was found unsupervised in the facility parking lot, 38 feet from a heavily traveled street. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-610 on 8/29/2020 at 6:32 PM in the DON office. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective 8/16/2020 through 9/3/2020. An acceptable removal plan, which removed the immediacy of the jeopardy, was received on 8/30/2020 at 3:00 PM, and was validated onsite by the surveyors on 8/30/2020 through 9/4/2020 by medical record review, in-service training record review, audit form review, and staff interviews. The findings include: Review of the facility's policy titled, Elopement 689, approved on 1/2020, showed, .Staff shall evaluate, investigate and report all cases of missing residents .Elopement occurs when a resident leaves the premises of a safe area without authorization .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse .When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file Accident /Incident Report .and .Document the event in the resident's medical record .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders. Examples of resident behavior requiring such actions are .Wandering not conducive to the safety of the resident or other residents in the community .New wandering behavior or attempted elopement will be .documented in the Nurses Note as to effect of interventions. Update Care Plan . Review of the facility's policy titled, .Abuse Investigations F600, F602, F603, F607, F610, revised 1/2020, showed, .reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .the Administrator or his/her designee, will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, as a minimum .Review the resident's medical record to determine events leading up to the incident .Interview the resident (as medically appropriate) .Interview all staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Review all events leading up to the alleged incident . Review the facility's policy titled, Amber Alert Drills, dated 6/15/2020, documented, .Resident Head Count . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering and Elopement Evaluation dated 5/27/2020, showed Resident #1 had severe cognitive impairment, a history of wandering/exit seeking behavior, and stayed near the exits. Resident #1 lacked safety awareness of current situation and had a wanderguard (ankle or wrist band tracking system that automatically locks and alarms the doors when the device is near the exit door). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 scored a 1 on the Brief Interview for Mental Status (BIMS) scale, which indicated Resident #1 had severe cognitive impairment. Review of an Incident Report dated 8/16/2020 at 4:38 PM, showed, .Reported to nurse per Rehab (Rehabilitation) Manager resident noted in lower parking lot in w/c (wheelchair) . This Incident Report was completed on 8/17/2020 by Licensed Practical Nurse (LPN) #3, the nurse responsible for Resident #1's care on 8/16/2020, at the direction of the Unit Manager as LPN #3 was unaware of the elopement on 8/16/2020. Review of the CAD Report dated 8/16/2020 at 4:43 PM, showed the Police Department received a 911 phone call from a passing motorist that a patient was in a wheelchair sitting toward the bottom of the parking lot. During an interview on 8/28/2020 at 10:45 AM, the Human Resources Director stated, .(Therapy Program Manager) looks at me and tells me to call .(Administrator) .and she started running. I looked up and saw (Resident #1). He was at the bottom parking lot .He was in the parking spaces. He was 15 (to) 20 feet away from the street .It is a main thoroughfare .by the time I got to him, she was pushing him back to the building .We noticed a police car was driving through our parking lot .Staff did not realize he was gone . Review of a computerized Nurse's Note dated 8/16/2020 at 5:00 PM and with a created date of 8/17/2020 at 1:18 PM, showed Resident #1 was sitting in a wheelchair in the parking lot wearing a wanderguard and the staff assisted the resident back in the building. LPN #3 documented this late entry but was unaware the resident was out of the building on 8/16/2020 even though she was the nurse responsible for Resident #1's care. The facility investigation did not identify why Resident #1's charge nurse was not informed of his elopement. Review of a Nurse's Note dated 8/17/2020 at 1:18 PM, and charted as a late entry, showed on 8/16/2020 at 5:00 PM, the Nurse Practitioner was made aware, and the nurse attempted to call the family. Review of the Social Worker's Progress Notes dated 8/18/2020, showed the family was not notified about the elopement until 2 days after the elopement. Review of the Physician's Progress notes dated 8/24/2020, showed the Medical Director was not notified about the elopement until 8/24/2020, 8 days after the elopement. During an interview on 8/29/2020 at 1:02 PM, the Unit Manager confirmed staff should notify the family and physician, they should attempt three times, and document attempts to notify. The investigation did not show the reason for the delay in contacting the family and the Medical Director about the elopement. Review of the facility's investigation showed no documentation a head count was performed after the elopement. During an interview on 8/28/2020 at 5:27 PM, the Administrator confirmed he was not able to provide any documentation a head count was done after the elopement. During a telephone interview on 8/28/2020 at 5:49 PM, Certified Nursing Assistant (CNA) #4 confirmed she worked in the facility the day of the elopement. She stated she wasn't told to do a head count. The investigation did not identify the reason staff did not perform a head count of all residents immediately after the elopement. Review of the medical record, showed there was no documentation a full assessment or vital signs were completed for Resident #1 immediately following the elopement. During a telephone interview on 8/28/2020 at 2:34 PM, LPN #4 stated, .I was not asked to do an assessment. He was not my patient. I just stopped to get his vital signs. I did not know he had eloped . LPN #4 was asked if she was in-serviced on wanderguard monitoring. She stated, I have no idea. LPN #4 was asked where she documented the vital signs. She stated, I gave them to the nurse manager and (named Human Resources) . The investigation did not identify the breakdown in communication that led to Resident #1 not receiving a full assessment after the elopement. During an interview on 8/28/2020 at 3:48 PM, CNA #3 confirmed she was the CNA responsible for Resident #1 the day he eloped. She stated, .I did not know he had gotten out of the building. I was not aware the alarm set off .Then I saw (named Therapy Program Manager) and (named Human Resources employee) bring him back in the building. I asked (named Therapy Program Manager) what happened. She told me it was not my business and it's not to be talked about. (named Human Resources employee) started to tell me and (named Therapy Program Manager) stopped her. They did not have me do anything with him. I tried to ask the nurse and she pushed me off .I did not receive any training prior to the incident. The wanderguards don't get checked like they are supposed to .I was never trained to check the placement. I was never told to check the wanderguards. CNA #3 was asked if she did a head count. She stated, I wasn't told to do one. CNA #3 stated she was very frustrated and had turned in her resignation 8/28/2020. Review of Resident #1's August 2020 Treatment Administration Record (TAR) showed wanderguard function and placement monitoring was not documented as performed on 8/11/2020 night shift, 8/13/2020 night shift, 8/15/2020 night shift, 8/16/2020 night shift (after the elopement), 8/18/2020 night shift, 8/22/2020 night shift, 8/26/2020 night shift, and 8/28/2020 night shift. The facility investigation did not identify that wanderguard checks were not being conducted, or identify staff who did not know how to monitor the wanderguards. During an interview conducted on 8/27/2020 at 2:20 PM, the Administrator was asked for any additional information related to the facility's investigation for Resident #1's elopement on 8/16/2020. The Administrator stated, .will e-mail information . The facility failed to e-mail additional information related to the facility's investigation. During an interview on 8/28/2020 at 6:35 PM, the Therapy Program Manager confirmed she discovered Resident #1 had left the building and she found him in the lower parking lot and brought him back into the building. The Therapy Program Manager was asked why she told CNA #3 to mind her own business and why she did not inform CNA #3 her resident had eloped. She stated it was not her job to alert everyone, and stated, I made aware of who needed to know . She stated, I don't remember telling anyone to do a head count .no one handed me any vital signs .I am not clinical .They should have turned to their clinical staff . The Therapy Program Manager was asked if she reported the elopement to the nurse in charge of Resident #1. She stated, I can't say who I reported it to in the facility . Review of a Timeline of the elopement investigation, presented by the Regional Nurse Consultant did not show a date the timeline was started or completed. Review of the investigation provided by the facility showed no interviews with alert and oriented residents. The only interview conducted and signed by the Regional Nurse Consultant, was with Resident #1, a severely cognitively impaired resident. The interview was not dated. Review of an undated ELOPEMENT CHECK LIST, showed, .Ad Hoc (Quality Assurance Performance Improvement (QAPI)) meeting was completed, messages left for Medical Director 8.18.20 (8/18/2020) . The facility investigation did not identify why Resident #1's charge nurse was not informed of his elopement, the breakdown in communication that led to Resident #1 not receiving a full assessment after the elopement, the reason staff did not perform a head count of all residents immediately after the elopement, the reason for the delay in contacting the family and the Medical Director about the elopement, the reason wanderguard checks were not being conducted consistently, or identify staff who did not know how to monitor the wanderguards, and did not show the Medical Director's specific input for the improvement plan during the Ad Hoc QAPI meeting on 8/18/2020. The surveyors verified the removal Plan by: 1. On 8/17/2020, the staff reassessed Resident #1 for wandering and elopement risk and the Care Plan was updated to reflect close supervision. The surveyors reviewed the assessment and the Care Plan. 2. On 8/18/2020, current residents noted to be at moderate risk were reviewed for appropriate assessments and Care Plans. Any residents with discrepancies had their assessments and care plans updated. The surveyors reviewed the assessments and the Care Plans. 3. On 8/18/2020, Care Plans were updated as necessary for all other residents identified to be at risk for wandering. 4. Education of all staff began on 8/29/2020 and was completed on 9/1/2020. The education included policy and procedures regarding resident elopement and what staff should do if a resident left the premises or a safe area without authorization. All staff were educated on the steps to take in the event of a resident elopement. Staff who have not been educated on the policies and procedures regarding resident elopement will be unable to work their shift until the education is completed. The surveyors reviewed the in-service training records and interviewed staff on all shifts. 5. The Administrator and DON were re-educated on how to complete and document the investigation and elopement immediately after the resident is made safe. The surveyors reviewed the training records and interviewed the Administrator. 6. All staff were re-educated on the policy titled, Abuse Investigations. Staff who have not been educated on the policies and procedures regarding resident elopement will be unable to work their shift until the education is completed. The surveyors reviewed the in-service records, education performed, and interviewed all staff on all shifts. 7. The Administrator and/or DON will review any potential abuse allegations and investigations and monitor for timely and thorough investigations weekly x (times) 4 and monthly x 3. The surveyors reviewed the audit forms and interviewed the Administrator. 8. Abuse investigations will be reviewed in Quality Assurance Performance Improvement (QAPI) monthly x 3 and changes will be implemented as required through the review. The surveyors interviewed the Administrator. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plan interventions were implemented for 4 of 5 sampled residents (Resident #1, #3, #4 and #5) reviewed for wandering, exit-seeking behaviors, and elopement. The facility's failure resulted in Immediate Jeopardy (IJ) for Resident #1 when he exited the facility in his wheelchair through the front door, crossed the front parking lot and stopped in a lower parking lot, 38 feet from a heavily traveled street. The facility was cited a deficiency at F-656 on 8/29/2019 at a scope and severity level of D as a result of the elopement of a resident into the heavily traveled street in front of the facility. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-656 on 8/29/2020 at 6:32 PM, in the DON's office. The facility was cited Immediate Jeopardy at F-656 at a scope and severity of J. The IJ was effective from 8/16/2020 through 9/3/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/30/2020 at 3:00 PM, and was validated onsite by the surveyors on 8/30/2020 through 9/4/2020 through review of policies related to active exit-seeking behaviors, assessments performed, in-service training records, and staff interviews. The findings include: Review of the facility's policy titled, Care Plans - Comprehensive F656, F657, F658, revised 11/2017, showed a person centered care plan should be implemented for each resident that includes .measurable objectives and time frames to meet the residents medical, nursing, mental and psychological needs is developed for each resident . Review of the facility's policy titled, Routine Resident Checks, Use of Wanderguard System (ankle or arm band tracking system that automatically locks doors and alarms when the device is too close to an exit door), revised 7/2020, showed, .Staff shall make routine resident checks of those using a wanderguard to help maintain resident safety and well-being .Monitor placement each shift .Test and replace per manufacturer guidelines . Review of the facility's policy titled, Wandering, Unsafe Resident revised 11/2017 and last approved 1/2020 documented Policy Statement The facility will strive to prevent unsafe wandering .Policy Interpretation and Implementation .Staff will institute a detailed monitoring plan .for residents who are assessed to have high risk of elopement or other unsafe behavior . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/17/2019 and updated 8/17/2020, showed Resident #1 was at risk for elopement and wandering, had a history of [REDACTED]. The Care Plan Interventions dated 9/17/2019 and continued 8/17/2020, documented, .Identify pattern of wandering/elopement (behavior): Is wandering purposeful, aimless or escapist? Is resident looking for something? Does resident indicate the need for more exercise? Intervene as appropriate .Increased supervision by staff which may include q (every) 15 min (minute) checks and 1:1 supervision .Wander guard placement per protocol . Review of the Wandering and Elopement Evaluation dated 5/27/2020, showed Resident #1 had severe cognitive impairment, had a history of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Prior to the elopement of Resident #1 on 8/16/2020 there was no documentation of monitoring for exit seeking behavior. Review of Resident #1's August 2020 Treatment Administration Record (TAR), showed wanderguard function and placement monitoring was not documented as performed on the night shift for 8/ 0, 8/13/2020, 8/15/2020, 8/16/2020, 8/18/2020, 8/22/2020, 8/26/2020, and 8/28/2020. Behavior monitoring was not initiated on the TAR until 8/19/2020, after the elopement, when Regional Nurse Consultant #1 suggested staff document behaviors on the TAR. Observation in the resident's room on 8/26/2020 at 5:10 PM, 8/28/2020 at 12:42 PM, 8/29/2020 at 3:55 PM, 8/30/2020 at 10:40 AM and 11:40 AM, and on 9/1/2020 at 9:28 AM, showed Resident #1 had a wanderguard device intact to his left ankle. During a telephone interview on 8/29/2020 at 2:10 PM, the Minimum Data Set (MDS) Coordinator confirmed she had identified Resident #1 had wandering and exit seeking behaviors and updated the Care Plan on 9/17/2019 to reflect the need for behavior monitoring. She stated the Certified Nursing Assistants (CNA) had been documenting behavior monitoring, but Regional Nurse Consultant #1 had told them .it would be better to put it on the TAR so nursing staff could monitor it . The CNAs and licensed nurses were both responsible for documenting resident behaviors at the time of the elopement. The MDS Coordinator confirmed she had identified some problems with licensed nursing documentation. She confirmed there was no documentation of behavior monitoring until 8/19/2020, and there was no documentation of wanderguard placement and functioning on the night shift for 8/11/2020, 8/13/2020, 8/15/2020, 8/16/2020, 8/18/2020, 8/22/2020, 8/26/2020, and 8/28/2020. Review of the medical record showed, Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 6/3/2020, showed, .at risk for wandering/elopement as evidenced by exit seeking behaviors .Interventions .Distract (resident) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Monitor function and placement of wanderguard . Review of the Wandering and Elopement Evaluation for Resident #3 dated 6/17/2020, showed, .New Behavior .History of exit seeking at home or other setting, including current setting .stays near exit door .lacks safety awareness .Dementia .Immediate interventions include .Wanderguard . Review of Resident #3's August 2020 TAR, showed wanderguard function and placement monitoring was not documented as performed on the night shift on 8/1/2020, 8/13/2020, 8/15/2020, 8/16/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, and 8/26/2020. Observations in the resident's room on 8/28/2020 at 1:02 PM, 8/29/2020 at 4:12 PM, 8/29/2020 at 5:30 PM, and 8/30/2020 at 10:45 AM, showed a wanderguard was intact to Resident #3's right ankle. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Wandering and Elopement Evaluation dated 7/31/2020, showed, .New Behavior .History of exit seeking at home or other setting, including current setting .lacks safety awareness .Dementia .Immediate interventions include .Wanderguard . Review of Resident #4's Care Plan dated 8/4/2020, showed, .at risk for elopement as evidenced by a History of attempts to leave facility unattended, Impaired safety awareness .Interventions .Monitor/assess for onset of new or changed behaviors .Wanderguard bracelet applied . Review of the August 2020 TAR for Resident #4, showed wanderguard function and placement monitoring was not documented as performed on the day shift for 8/1/2020, 8/2/2020, 8/3/2020, 8/16/2020, and the night shift on 8/1/2020, 8/2/2020, 8/3/2020, 8/13/2020, 8/15/2020, 8/16/2020, 8/21/2020, 8/22/2020, and 8/26/2020. There was no documentation of behavior monitoring on the TAR until 8/29/2020. Observations in the resident's room on 8/28/2020 at 1:06 PM, 8/29/2020 at 4:05 PM, 8/29/2020 at 5:10 PM and 8/30/2020 at 10:50 AM, showed Resident #4 had a wanderguard intact to the right ankle. Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering and Elopement Evaluation dated 6/17/2020, showed, .New Behavior .History of exit seeking at home or other setting, including current setting .lacks safety awareness .Dementia .Immediate interventions include .Wanderguard . Review of the Care Plan for Resident #5 dated 6/18/2020, showed the resident was at risk for elopement and wandering. Interventions included .Monitor placement and function of wander alert bracelet (wanderguard) . Review of Resident #5's August 2020 TAR, showed wanderguard function and placement monitoring was not documented as performed on the day shift on 8/16/2020 and the night shift on 8/1/2020, 8/13/2020, 8/15/2020, 8/16/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, and 8/26/2020. Observations in the resident's room on 8/28/2020 at 1:03 PM, 8/29/2020 at 4:08 PM, and 8/30/2020 at 10:42 AM, showed a wanderguard intact to Resident #5's left ankle. During an interview on 8/29/2020 at 1:02 PM, the Unit Manager confirmed licensed nurses should be documenting behavior monitoring on the TAR every shift. The Unit Manager was asked how she monitors to ensure staff are monitoring and documenting behaviors. The Unit Manager stated they are monitored monthly, and she had identified some problems. She confirmed there was no behavior monitoring documentation for Resident #1 and #4. She confirmed the facility put behavior monitoring in place for Resident #1 on 8/19/2020, after the elopement. During an interview on 9/3/2020 at 1:55 PM, the DON confirmed nursing staff should have been monitoring behaviors for the residents at risk for wandering and elopement and should have been checking the wanderguards for placement and functioning every shift. The facility failed to ensure the Care Plan was followed to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in IJ for Resident #1 when he eloped from the facility. Refer to F-610, F-726, and F-689. The surveyors verified the Removal Plan by: 1. On 8/30/2020, the MDS Coordinator was re-trained on the policy which included to update the Care Plans with updated interventions as appropriate. The surveyors reviewed Resident #1's Care Plan and interviewed the MDS Coordinator. 2. On 8/30/2020, current residents noted to be at moderate risk were reviewed for assessment and appropriate Care Plan interventions. Care Plans were reviewed and updated as necessary for all other residents identified to be at risk for wandering. The surveyors reviewed the elopement risk assessments and Care Plans for residents. The surveyors interviewed staff on all shifts related to their responsibilities for care planning. 3. On 8/30/2020, licensed staff were re-educated on the Elopement Policy which included increasing the monitoring of residents who are exhibiting increased wandering or exit seeking behavior. Interventions identified by the elopement assessment will be put on the Kardex and/or TAR/Medication Administration Record [REDACTED]. The surveyors reviewed the in-service sign in sheets, audit forms, interviewed staff on each shift, and interviewed the Unit Managers. 4. Residents with elopement and wandering risk will be reviewed in Patient at Risk (PAR) meeting weekly, to ensure Care Plans meet their current needs. The surveyors interviewed members of the PAR meetings. Noncompliance of F-656 continues at a scope and severity E for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of the local Emergency Management System's Computer-Aided Dispatch Report (CAD), medical record review, observation and interview, the facility failure to ensure a safe environment and provide supervision to prevent an incident of elopement for 1 of 5 sampled residents (Resident #1) reviewed for wandering/elopement risk resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident assessed to be at a risk for wandering with exit seeking behaviors, exited through a door, and was found unsupervised in the facility parking lot on 8/16/2020. Resident #1 was last seen by facility staff at 4:15 PM. At 4:38 PM the resident was found by the Therapy Program Manager and the Human Resources employee outside the facility unattended, 38 feet from a heavily traveled street. The facility was unaware of Resident #1's location for 23 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility was cited a deficiency at F-689 on 8/29/2019 at a J as a result of the elopement of a resident into the heavily traveled street in front of the facility. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 8/29/2020 at 6:32 PM, in the DON Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 8/16/2020 through 9/3/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/30/2020 at 3:00 PM, and was validated onsite by the surveyors on 8/30/2020 through 9/4/2020 by policy review, observation, medical record review, review of education records, and staff interviews. The findings include: Review of the facility's policy titled, Elopement 689, approved on 1/2020, showed, .Staff shall evaluate, investigate and report all cases of missing residents .Elopement occurs when a resident leaves the premises of a safe area without authorization .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse .When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file Accident /Incident Report .and .Document the event in the resident's medical record .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders. Examples of resident behavior requiring such actions are .Wandering not conducive to the safety of the resident or other residents in the community .New wandering behavior or attempted elopement will be .documented in the Nurses Note as to effect of interventions. Update Care Plan . Review the facility's policy titled, Amber Alert Drills, dated 6/15/2020, documented, .Resident Head Count . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Wandering and Elopement Evaluation dated 5/27/2020, showed Resident #1 had severe cognitive impairment, had a history of [REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had severe cognitive impairment, wandering behaviors, required extensive 2-person assistance for transfers, limited assistance with 1-person physical assistance when in a wheelchair, and no impairment to upper and lower extremities. Review of Resident #1's Care Plan dated 8/11/2019 and revised 9/17/2019, showed, .(Named Resident) has impaired cognitive function or impaired thought process r/t (related to) Dementia .has been determined to be an elopement risk/wanderer .Disoriented to place .History of attempts to leave the facility unattended .Impaired safety awareness . The wanderguard was initiated on 9/17/2019. Observation in the resident's room on 8/26/2020 at 5:10 PM, 8/28/2020 at 12:42 PM, 8/29/2020 at 3:55 PM, 8/30/2020 at 10:40 AM and 11:40 AM, and on 9/1/2020 at 9:28 AM, showed Resident #1 had a wanderguard intact to his left ankle. Review of the Medication Administration Record [REDACTED]. Prior to the elopement of Resident #1 on 8/16/2020 there was no documentation of monitoring Resident #1 for exit seeking behavior . Review of an Incident Report dated 8/16/2020 at 4:38 PM, showed, .Reported to nurse per Rehab (Rehabilitation) Manager (Therapy Program Manager) resident noted in lower parking lot in w/c (wheelchair) . This Incident Report was completed on 8/17/2020 by Licensed Practical Nurse (LPN) #3, the nurse responsible for Resident #1's care on 8/16/2020, at the direction of the Unit Manager as LPN #3 was unaware of the elopement on 8/16/2020. Review of the CAD Report dated 8/16/2020 at 4:43 PM showed the Police Department received a 911 phone call from a passing motorist that a patient was in a wheelchair sitting toward the bottom of the parking lot. At this time the facility was unaware the resident was missing from the facility. Review of a computerized Nurse's Note dated 8/16/2020 at 5:00 PM with a created date of 8/17/2020 at 1:18 PM, showed Resident #1 was sitting in a wheelchair in the parking lot wearing a wanderguard and the staff assisted the resident back in the building. LPN #3 documented this late entry on 8/17/2020, but was unaware the resident was out of the building on 8/16/2020 even though she was the nurse responsible for Resident #1's care on 8/16/2020. Review of a Social Services Communication Note dated 9/1/2020, showed, .(Resident #1) got outside the building last week .He just pushed the door open until the 15 sec (seconds) it takes (for the door to automatically unlock). The alarm went off but staff thought it was (Named Resident #4) so they reset it and walked away. Staff found him (Resident #1) alone in the parking lot at the edge of the pavement and grass, pilfering around in grass . During an interview on 8/26/2020 at 1:54 PM, the Therapy Program Manager that located the resident outside the facility stated, I was walking towards my car .and (Named Human Resources) was behind me on the phone .I noticed someone in a hat and in a wheelchair in the back parking lot .it was (Named Resident #1). During an interview on 8/28/2020 at 10:45 AM, the Human Resources Director stated, .(Therapy Program Manager) looks at me and tells me to call .(Administrator) .and she started running. I looked up and saw (Resident #1). He was at the bottom parking lot .He was in the parking spaces. He was 15 (to) 20 feet away from the street .It is a main thoroughfare .by the time I got to him, she was pushing him back to the building .We noticed a police car was driving through our parking lot .Staff did not realize he was gone . During an interview on 8/28/2020 at 2:32 PM, Licensed Practical Nurse (LPN) #3 stated, .I did not know he had gotten out . She stated that she received a call on 8/17/2020 from the Unit Manager and was told to enter a note and complete an incident report in the computer. She stated she was told what information to document and had not gotten any information on 8/16/2020 about the elopement even though she was the nurse responsible for Resident #1's care. LPN #3 stated it was the next day (8/17/2020) before she knew about the elopement, even though she was the LPN responsible for Resident #1's care on 8/16/2020. She stated once the Incident Report information was entered in the computer, it could be back dated. The Incident Report was not completed until 8/17/2020 at 4:38 PM. She confirmed she did not complete the Incident Report until the day after the occurrence. LPN #3 confirmed there was no assessment completed for Resident #1 after re-entry into the facility as she was unaware at the time the resident had eloped. She confirmed Resident #1 was not placed on close supervision after the elopement. During a telephone interview on 8/28/2020 at 2:34 PM, LPN #4 stated, .I was not asked to do an assessment. He was not my patient. I just stopped to get his vital signs. I did not know he had eloped . LPN #4 was asked if she was in-serviced on wanderguard monitoring. She stated, I have no idea. LPN #4 was asked where she documented the vital signs. She stated, I gave them to the nurse manager and (named Human Resources) . During an interview on 8/28/2020 at 3:48 PM, Certified Nursing Assistant (CNA) #3 confirmed she was the CNA responsible for Resident #1 the day he eloped. She stated, .I did not know he had gotten out of the building. I was not aware the alarm set off .Then I saw (named Therapy Program Manager) and (named Human Resources) bring him back in the building. I asked (named Therapy Program Manager) what happened. She told me it was not my business and it's not to be talked about. (named Human Resources) started to tell me and (named Therapy Program Manager) stopped her. They did not have me do anything with him. I tried to ask the nurse and she pushed me off .I did not receive any training prior to the incident. The wanderguards don't get checked like they are supposed to .I was never trained to check the placement. I was never told to check the wanderguards. CNA #3 was asked if she did a head count. She stated, I wasn't told to do one. CNA #3 stated she was very frustrated with the situation in the facility, and had turned in her resignation 8/28/2020. During an interview on 8/28/2020 at 5:27 PM, the Administrator was asked if all staff should be made aware of an elopement. The Administrator stated, .Absolutely . The Administrator was asked about the head count after the elopement. The Administrator stated, I don't have anything but the midnight census .I can't confirm or deny the bed (head) count was done after (Named Resident #1) eloped . The Administrator confirmed the head count was not performed until 8/17/2020 at 1:45 AM. During observation and interview on 8/28/2020 at 6:15 PM, the Therapy Program Manager confirmed Resident #1 had exited the facility through the front doors, crossed the front parking lot, and stopped in the lower parking lot. The Therapy Program Manager used a measuring wheel and confirmed Resident #1 had traveled a distance of 201 feet from the facility's front door and was located 38 feet from a heavily traveled street in front of the facility. During an interview on 8/28/2020 at 6:35 PM, the Therapy Program Manager confirmed she discovered Resident #1 had left the building and she found him in the lower parking lot and brought him back into the building. The Therapy Program Manager was asked why she told CNA #3 to mind her own business and why she did not inform CNA #3 her resident had eloped. She stated it was not her job to alert everyone, and stated, I made aware of who needed to know . She stated, I don't remember telling anyone to do a head count .no one handed me any vital signs .I am not clinical .They should have turned to their clinical staff . The Therapy Program Manager was asked if she reported the elopement to the nurse in charge of Resident #1. She stated, I can't say who I reported it to in the facility . During an interview on 8/29/2020 at 2:54 PM, LPN #4 stated she did not do one on one supervision of Resident #1 after the elopement. She was asked if she did a head count after the elopement. She stated, No, I did not. She stated, I had no idea of what was going on. Observation at the Nurse's Station on 8/30/2020 at 11:48 AM, showed a door alarm sounding. LPN #1 and LPN #2 were sitting in the nurse's station talking and did not get up to check the doors when the alarm sounded. During an interview on 8/30/2020 at 12:00 PM, LPN #1 and LPN #2 confirmed they did not know the alarm was a door alarm. At that time, the Administrator walked up to the nurse's station and confirmed it was the door alarm sounding. During a telephone interview on 9/3/2020 at 1:55 PM, the DON confirmed staff should be aware of an elopement, an assessment should be completed after a resident elopes as soon as they are back in the facility, and Resident #1 should have been placed on close supervision after he eloped. The facility did not conduct a thorough and timely investigation of Resident #1's elopement and did not ensure Care Plan interventions were implemented. The failure to ensure a safe environment and adequate supervision for Resident #1, a vulnerable resident with severe cognitive impairment with wandering/exit seeking behaviors, resulted in Immediate Jeopardy when Resident #1 was found unsupervised in the facility parking lot close to a heavily traveled street by 2 staff members. Resident #1's direct care staff were unaware Resident #1 was missing. The facility was unaware of Resident #1's location for 23 minutes. The surveyors verified the Removal Plan by: 1. On 8/18/2020, a new Nursing and Wandering Elopement Assessment was completed. The surveyors reviewed the new Nursing and Wandering and Elopement Assessment and interviewed staff on all shifts. 2. On 8/18/2020, the elopement book was updated to ensure each resident who is at risk for elopement had an Elopement Check List, face sheet, and picture. The surveyors reviewed the elopement book to ensure it had an Elopement Check List, and was updated with resident pictures. 3. On 8/18/2020, current residents noted to be at moderate risk were reviewed for appropriate assessments and appropriate Care Plans. Any residents with discrepancies had assessments and Care Plans updated. The surveyors reviewed the assessments and Care Plans. 4. On 8/18/2020, Care Plans were reviewed and updated as necessary for all other residents identified to be at risk for wandering. The surveyors reviewed the Care Plans for residents to be at risk for wandering and interviewed staff on all shifts. 5. On 8/26/2020, the Elopement policy was reviewed to ensure it was updated to include notification of the Administrator and Director of Nursing (DON) when an elopement occurs, and to include a new wandering elopement assessment. Based on new assessment, resident's care plan and supervision will be updated to reflect resident's safety needs. The surveyors reviewed the revised Elopement policy. 6. On 8/29/2020, a nursing order was added to Resident #1's medical record for licensed nurses to monitor for exit seeking behaviors every shift and added to the exiting task in Point of Care to monitor for wandering behaviors. The surveyors reviewed the medical record to ensure the order to monitor exit seeking behaviors, and reviewed Point of Care to ensure the exiting task has been added. 7. Education of Licensed Nursing Staff began on 8/29/2020 and was completed on 9/1/2020. The education included the steps to be taken once the resident is returned to the community that included: a) Examine the resident for injuries. b) Contact the attending physician and report findings and conditions of the resident. c) Notify the resident's legal representative. d) Notify search teams that the resident has been located. e) Complete and file an incident report. f) Complete a new Wandering and Elopement evaluation, update the Care Plan, Treatment Administration Record (TAR), Medication Administration Record [REDACTED]. g) Staff were re-educated on completing a head count immediately. h) The nursing staff were re-educated on documentation expectations in regards to behavior monitoring. i) The staff were educated to complete a visual out of doors check upon hearing the alarm to ensure that only one resident had tripped the alarm. j) The staff were re-educated on the documentation for wander guard monitoring. Staff who have not been educated on the above by 8/30/2020 will not begin their shift until such education is completed. This included any staff that are currently off or on leave. The surveyors reviewed the in-service records, the education performed, and interviewed staff on all shifts. 8. The Administrator will monitor staff response to alarm triggers during the elopement drills to ensure outdoor visual checks occur. The surveyors observed an elopement drill on 9/1/2020. 9. Wanderguard documentation will be reviewed daily times (x) 7, weekly x 4, monthly x 3 for completeness by the DON/designee. The surveyors reviewed an audit completed on 9/1/2020. 10. Point of Care documentation will be reviewed daily x 7, weekly x 4, and monthly x 3 by the DON/designee. The surveys reviewed the audit review forms. 11. Residents with moderate to high risk for wandering or elopement behavior will be reviewed in the Patient at Risk meeting weekly and as needed based upon new behaviors by the Interdisciplinary (IDT) team. The surveyors reviewed documentation of the meeting conducted on 9/3/2020 and interviewed Interdisciplinary Team (IDT) members. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on policy review, National Weather Service record, medical record review, observation, and interview, the facility failed to ensure adequate supervision and monitoring for 4 of 4 (Resident #38, #44, #272, and #422) cognitively impaired, vulnerable residents who had wandering and exit seeking behaviors. The failure of the facility to ensure a safe environment and adequately supervise residents placed Resident #38 in Immediate Jeopardy. Resident #38 was a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 15 minutes before staff saw the resident outside the facility unsupervised and realized he had eloped from the facility. Resident #38 was found by a staff member in his wheelchair on a heavily traveled street beside the facility. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM, in the Assistant Director of Nursing (ADON) Office. F-689 was cited at a scope and severity of J. F-689 is Substandard Quality of Care. An extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM and the A[NAME] was validated onsite by the surveyor on 8/29/19 through review of assessments, policies related to exit seeking behavior, in-service training records, and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: 1. The facility's Elopement policy, revised (MONTH) (YEAR), documented, .Elopement occurs when a resident leaves the premise (premises) or a safe area without authorization .and/or any necessary supervision to do so .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate, 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders [REDACTED].documented in the Nurses Notes as to effect of interventions . The facility's Wandering, Unsafe Resident policy, revised (MONTH) (YEAR), documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The facility's Safety and Supervision of Residents policy, revised (MONTH) 2007 documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Wandering and Elopement Evaluation dated 6/28/19 revealed Resident #38 was assessed as low risk for wandering and elopement. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #38 was assessed to have a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The resident was visually impaired and had delusional behaviors. He was not assessed to have wandering behaviors. Medical record review of a Nurses' Note dated 8/15/19 revealed Resident #38 was anxious and agitated and was exhibiting exit-seeking behaviors such as lingering around exit doors and trying to push the doors open. A physician's orders [REDACTED].Wanderguard r/t (related to) elopement risk . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 (the day his exit seeking behaviors began) revealed Resident #38 was reassessed as a low risk for wandering. Medical record review of the Comprehensive Care Plan revised 8/15/19 revealed Resident #38 was an elopement risk and had wandering tendencies due to impaired safety awareness. The interventions included to distract the resident from wandering by offering diversional activities, to document wandering behaviors and attempted diversional activities, and to check placement of wanderguard per protocol. The facility was unable to provide a protocol for wanderguards. A Nurses' Note dated 8/20/19 at 3:30 PM documented, .staff reported resident was observed outside. therapy (Therapy) and nursing staff obtained resident from road next to parking lot entrance. Resident was in his w/c (wheelchair), self propelling to road. resident (Resident #38) exited facility from exit door near chapel that exits to parking lot .wander guard remains in place to right ankle . Review of a Wandering and Elopement Evaluation dated 8/20/19, after Resident #38 eloped from the facility, revealed moderate risk for wandering and elopement. The National Weather Service records revealed the recorded high temperature for the facility area on 8/20/19 (the day of the elopement from the facility) was 95 degrees Fahrenheit. The facility is located near a school on a hill. The road is heavily traveled by traffic and has limited visibility. Medical record review revealed after Resident #38 exhibited exit seeking behaviors, there was no nursing documentation in the progress notes between 8/15/19 and 8/20/19 related to any type of exit seeking behaviors. Observations in the Dining Room on 8/25/19 at 10:15 AM, revealed Resident #38 was sitting in a wheelchair, wearing glasses, and had a wanderguard on his right ankle. Interview with Licensed Occupational Therapist (OT) on 8/26/19 at 11:18 AM, in the ADON Office, the OT was asked to review her written statement and sign and date it if there were no changes. The statement dated 8/20/19 read as follows, At approximately 3:30 PM I was sitting in my car in the parking lot talking with my ride .I looked out to see (Named Resident #38) self-propelling his wheelchair in the road . At this time the OT changed her statement to read, .(Named Resident #38) was seen self-propelling toward the road, not in the road . The OT wrote this statement at the bottom of her previous written statement. The OT was asked where Resident #38 was when she found him. The OT stated, Where the parking lot and road meet . The OT was asked what the weather conditions were outside at the time. The OT stated, Hot. Observation and interview with the OT on 8/26/19 at 11:45 AM, in the facility's parking lot, the OT stated, We were parked in the 3rd parking spot and there were no cars beside us so we could see where he (Resident #38) was . The OT was asked to clarify why she stated Resident #38 was in the road on her original statement. The OT stated, Because I thought he (Resident #38) was in the road when I first saw him .his wheelchair was literally sitting right here (pointed with her toe to the line where the pavement of the facility's parking lot met the pavement of the heavily traveled city street) . Observations in the East Hall on 8/26/19 at 2:36 PM, revealed Resident #38 was self-propelling in a wheelchair and had a wanderguard on his right ankle. Interview with CNA #5 on 8/26/19 at 3:01 PM, in the ADON Office, CNA #5 confirmed she was working the East Hall the day Resident #38 eloped from the facility. CNA #5 was asked if she observed the incident. CNA #5 stated, No ma'am .heard them (staff) yelling and running toward the front door .saw them (staff) bringing him (Resident #38) back from the road and a school bus had stopped. Telephone interview with Licensed Practical Nurse (LPN) #2 on 8/26/19 at 4:13 PM, LPN #2 confirmed that she was Resident #38's assigned nurse that day (8/20/19) and Resident #38 was beside her at the Nurses' Station at 3:15 PM. LPN #2 was asked if Resident #38 had tried to get out of the facility before this incident. LPN #2 stated, He (Resident #38) wanders around a lot and will push on the doors . LPN #2 was asked when Resident #38 first began exhibiting exit-seeking behaviors. LPN #2 stated, Maybe a few weeks ago. LPN #2 was asked the outcome of the facility's investigation of the incident. LPN #2 stated, We found out he had gotten out that back door (East Hall exit door). LPN #2 was asked if the door was unlocked when she checked it after Resident #38 eloped from the facility. LPN #2 stated, Yes .the Administrator was the one who first discovered it (East Hall exit door) was unlocked and he told me .I put the key in .locked it .checked it. Interview with the Administrator on 8/26/19 at 4:42 PM, in the ADON Office, the Administrator confirmed that he was in his office when Resident #38 eloped from the facility and once the resident was back in the facility, he began checking exit doors. He stated, .it had rained .and it was easy to see there were wheelchair tracks from the exit door to the left of therapy (East Hall exit door), opposite the smoking entrance. When I pushed on the door, it opened without the delayed egress. I looked up and the light was green indicating .mag (magnet) lock was unlocked . The Administrator stated, (Named LPN #2) .remembers that a coroner took a body out that door (on 8/14/19) and that's the only time she remembered it being unlocked . The Administrator was asked if the East Hall exit door could have been left unlocked for 6 days. The Administrator stated, .the likely thing that should happen, is if someone takes a key and unlocks it, they should relock it . Interview with the Maintenance Director on 8/26/19 at 5:09 PM, in the ADON Office, the Maintenance Director was asked about the incident where Resident #38 eloped from the building. The Maintenance Director stated, I was notified by (Named Administrator). He called me and asked who had keys to the door .I check the doors every week .I have all week to do the (Named maintenance documentation system) but basically, I check them every morning. The Maintenance Director was asked how he could tell the door was locked. The Maintenance Director explained the locking mechanism and stated, It makes a noise, you turn it all the way to the right to the green then back to the center and the light turns to red and that resets it. The Maintenance Director confirmed he locked the door per this procedure on 8/14/19. Per the Maintenance Director's documentation the door was checked and documented as locked on 8/14/19. There was no other documentation of a door checks on the exit doors until 8/21/19. Telephone interview with CNA #4 on 8/27/19 at 9:23 AM, CNA #4 confirmed she was working when Resident #38 eloped from the building. CNA #4 stated, I'm not sure what happened .was walking down North Hall, looked out the windows .saw a man in a wheelchair .realized who it was (Resident #38) .I saw the bus through the window and [MEDICATION NAME] kicked in .one of the therapists had already seen him (Resident #38) and was bringing him back from the road to the parking lot . Observations in the Dining Room on 8/27/19 at 11:38 AM, revealed Resident #38 slowly rolled his wheelchair backward and forward using his feet and had a wanderguard on his right ankle. Observations from facility's parking lot on 8/27/19 from 3:00 PM to 3:55 PM, revealed several school buses and a heavy flow of traffic on the road. Telephone interview with (Named School Bus Driver) on 8/28/19 at 5:02 PM, (Named School Bus Driver) was asked if she saw a person in a wheelchair beside the road close to the facility on the afternoon of 8/20/19. (Named School Bus Driver) stated, Yes Ma'am. He (Resident #38) was in the road .I stopped pretty far back and put my signs out and my light on so that nobody would pass me or my bus . Observations in the hallway by the Rehabilitation (Rehab) Department on 8/29/19 at 9:05 AM, revealed Resident #38 attempted to reach the East Hall exit door on the parking lot side of the hallway. Staff were between the door and Resident #38, and were redirecting Resident #38. Observations outside of the facility on 8/29/19 at 2:08 PM, revealed the Rehabilitation Director measured the distance in linear feet from the exit door where Resident #38 eloped to the heavily traveled street. The distance was 146 linear feet to the road. 3. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan revised 7/7/19 documented, (Named Resident #44) is an elopement risk/wanderer .wanders aimlessly .Interventions .Placement of wanderguard per protocol. Monitor for placement and in working order. Date Initiated: 10/18/2017 Medical record review of a Wandering and Elopement Evaluation dated 7/8/19 revealed Resident #44 was assessed as low risk for wandering and elopement. Medical record review of the quarterly MDS for Resident #44 dated 7/11/19 revealed a BIMS of 1 which indicated severe cognitive impairment. The physician's orders [REDACTED].Monitor placement and function of wanderguard two times day . Medical record review of Resident #44's (MONTH) and (MONTH) 2019 Activity of Daily Living (ADL) task list revealed there was no documentation of monitoring wanderguard equipment checks for the day shift on 7/7/19, 8/11/19, 8/12/19, or 8/25/19, and there was no documentation for either shift on 8/13/19 through 8/24/19. Observations in the Dining Room on 8/26/19 at 9:30 PM, revealed Resident #44 walking around in the Dining Room. Observations in the North hallway on 8/28/19 at 8:49 AM, revealed Resident #44 walking up and down the hallway. Interview with the DON on 8/29/19 at 12:04 PM, in the ADON Office, the DON was asked how often should the wanderguards be checked. The DON stated, Every shift .we did not realize it (the checks) had dropped off (from the electronic documentation record) until we started looking for stuff for you all on the 25th of (MONTH) .they should have done paper charting when the task was dropped off . 4. Medical record review revealed Resident #272 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Wander guard (wanderguard) in place to left ankle . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 revealed Resident #272 was assessed as low risk for wandering and elopement. Medical record review of the Baseline Care Plan dated 8/16/19 documented, .Minimize Risk of Elopement .Wander Bracelet (wanderguard) . Medical record review of Resident #272's ADL task list documented, .August 2019 .MONITORING Wandering (monitor for wandering behaviors) .Q (every) shift . There was no documentation of wander monitoring for the day shift for 8/16/19, 8/17/19, 8/19/19, 8/20/19, 8/25/19, or 8/26/19, and for the night shift for 8/23/19 and 8/25/19. Medical record review of Resident #272's ADL facility task list for (MONTH) 2019 revealed there was no documentation of monitoring wanderguard equipment checks for the day shift for 8/16/19, 8/17/19, 8/22/19, 8/23/19, 8/25/19, and 8/26/19. Observations in the North hallway on 8/26/19 at 10:00 AM, revealed Resident #272 had a wanderguard to her left ankle walking to Activities with a staff member. Interview with CNA #1 on 8/26/19 at 1:11 PM, in the ADON Office, CNA #1 was asked if she was assigned to Resident #272 for the day. CNA #1 stated, Yes. CNA #1 was asked if Resident #272 had a wanderguard. CNA #1 stated, I don't know . CNA #1 was asked who was responsible to check the wanderguards. CNA #1 stated, I don't know. I would have to find that out . CNA #1 was asked how she would know if a resident had a wanderguard. CNA #1 stated, I just see it when I am getting her dressed. It is not a structured thing. Interview with LPN #1 on 8/26/19 at 3:23 PM, at the North Hall Nurses' Station, LPN #1 was asked if the CNAs should know if a resident had a wanderguard. LPN #1 stated, Absolutely. LPN #1 was asked when should CNAs look at the kardex (CNA Plan of Care for the resident) to know how to take care of the residents. LPN #1 stated, Daily, at the beginning of the shift to see if anything has changed. LPN #1 was asked if there would be a reason for a CNA who had taken care of a resident for 5 hours not to know a resident was a wanderer with a wanderguard in place. LPN #1 stated, Absolutely not. Interview with CNA #2 on 8/26/19 at 4:52 PM, at the North Hall Nurses' Station, CNA #2 was asked if she had reported to CNA #1 that Resident #272 had a wanderguard when she arrived to work on the North Hall to take care of the resident. CNA #2 stated, I did not. Interview with the DON on 8/27/19 at 6:20 PM, in the ADON Office, the DON was asked when was the wanderguard ordered for Resident #272. The DON stated, 8/15/19. The DON was asked when the wanderguard was placed on Resident #272. The DON stated, On 8/16 (19) . The DON confirmed there was no documentation the wanderguard was placed on 8/15/19. The DON was asked if Resident #272 was exit seeking. The DON stated, Sometimes she is. The DON confirmed the wanderguard functioning tests and wanderguard checks had not been performed. The DON was asked if she expected the CNAs to review a resident's kardex to know if a resident was exit seeking and if the resident had a wanderguard in place. The DON stated, Yes. 5. Medical record review revealed Resident #422 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing: Wandering & Elopement Evaluation dated 8/16/19 documented, .New Admission .Current Evaluation .Lacks safety awareness of current situation .Immediate interventions .wanderguard .Low Risk . Medical record review of a Baseline Care Plan for Resident #422 dated 8/17/19 documented, .Goal: Minimize Risk of Elopement .Interventions .Wander Bracelet (checked) . Medical record review of a Nurses' Note dated 8/20/19 documented, .Resident was standing at the front entrance and pushing on the door handle. She was very agitated and requesting to go outside as this nurse was attempting to leave for the day. Resident states she wants to 'get out of here.' Attempted to determine why she wanted to leave/go outside. She declined to answer questions stating that it was 'none of your business . Medical record review of a Nursing: Wandering & Elopement Evaluation for Resident #422 dated 8/25/19 documented, .Low Risk . Observations on 8/25/19 at 9:30 AM and 11:23 AM, revealed Resident #422 wandered the halls throughout the facility. Observations in the East hallway on 8/26/19 at 8:01 AM, revealed Resident #422 ambulated in the hallway with a staff member and held an ink pen and clipboard in her hand, Resident #38 was overheard telling staff member that she badly needs to find someone. A physician's orders [REDACTED].Wander guard (wanderguard) in place to right ankle . Interview with the DON on 8/27/19 at 6:30 PM, in the ADON Office, the DON was asked if a wanderguard was placed on Resident #422 on 8/20/19, when the resident was documented as exit-seeking. The DON stated, .I think it was on there before that but the (nursing) documentation says the 25th (8/25/19) .I honestly can't answer that question. It shouldn't have happened . The DON was asked if an elopement risk evaluation should have been completed when the resident was actively exit seeking on 8/20/19. The DON stated, Yes. Telephone interview with LPN #2 on 8/28/19 at 9:05 AM, LPN #2 was asked if she placed a wanderguard on Resident #422 after she assessed her on 8/20/19. LPN #2 confirmed Resident #422 did not have a wanderguard in place on 8/20/19 and stated, .I know I didn't place the wanderguard on the resident. Interview with the DON and the Administrator on 8/27/19 at 7:06 PM, in the ADON Office, the DON and Administrator were asked why a resident would have a wanderguard. The DON stated, .Exit seeking, wandering . The DON was asked how staff would know how to check wanderguards per protocol if the facility did not have a protocol. The DON stated, I know that the protocol was asked for and we don't have one . Interview with the Administrator on 8/28/19 at 5:25 PM, in the ADON Office, the Administrator was asked who was responsible to ensure care plan interventions, elopement evaluation forms, charting, and staff education were completed. The Administrator stated, The DON. The Administrator was asked who was responsible to ensure the residents were safe. The Administrator stated, The Administrator and the team. Every employee here . The failure of the facility to ensure a safe environment, the failure to provide adequate supervision and monitoring of residents with wandering and exit seeking behaviors resulted in Immediate Jeopardy for Resident #38, #44, #272, and #422. Resident #38 exited the facility through an unsecured exit door without staff knowledge and was found on a heavily traveled city street. The survey team verified the A[NAME] by: 1. Education was initiated with the Interdisciplinary Team (IDT) members on 8/27/19 by Administrator. All staff were re-educated regarding policies including Elopement; Safety and Supervision of Residents, and the Wanderguard Protocol on 8/27/19 by the DON, ADON, and/or designee. Education of staff will occur upon entering the facility for their scheduled shift. The survey team reviewed the in-service sign in sheets and interviews with staff on all shifts confirmed this. 2. Beginning on 8/27/19 the charge nurse will monitor Plan of Care (P[NAME]) documentation by the CNAs at the end of every shift to ensure P[NAME] documentation is completed, for ongoing compliance. Any behaviors will be documented and a P[NAME] alert will be sent to the Licensed Nursing Staff on the dashboard. Interviews with the DON, nurses, and CNAs on all shifts confirmed this. 3. Beginning on 8/28/19 the DON, ADON, and/or Designee will audit clinical alerts in (Named electronic charting for documentation) for compliance daily, in morning clinical meeting. Interviews with the DON and ADON confirmed this and the survey team reviewed the audit forms. 4. Beginning 8/27/19 if wandering or any behavior occurs during a shift, staff will follow current interventions, and place resident on 72 hour alert charting which monitors for effectiveness of interventions, followed by documentation in (Named electronic charting for documentation). Licensed Nurses will update Care Plan interventions as deemed appropriate. Interviews with the DON and Nursing staff on all shifts confirmed this. 5. Exit doors will be checked beginning 8/28/19 by the Maintenance Director and/or Housekeeping Supervisor hourly for proper operation/locking during normal shift hours Monday - Friday for two weeks, then decrease to twice daily for two weeks, then daily ongoing. After hour door checks will be completed hourly by the RN Supervisor, Charge Nurse, and/or designee. Checks will be placed on a log verifying that door checks were completed hourly. Audit log for exit doors was reviewed by the survey team. Interviews with the Maintenance Director, Housekeeping Supervisor, and Nursing staff on all shifts confirmed this. 6. Beginning 8/28/19 Daily rounds will be completed by Administration/Department Managers to include monitoring of door alarms for four weeks, then monthly. Interviews with the Administrator and Department Managers confirmed this. 7. On 8/28/19 the Kardex (CNA Care Plan) and daily tasks were reviewed and updated as necessary for wandering residents. Interviews with the Nursing and CNA staff on all shifts confirmed this. 8. Beginning 8/28/19 doors will not be unlocked without notification/consent from the Administrator. Interviews with the Administrator and staff on all shifts confirmed this. 9. Beginning 8/28/19 an Elopement Binder, which includes policies & procedures regarding Wandering Residents, is located at both Nurses' Stations. The survey team reviewed the Elopement Binder and interviews with Nursing staff on all shifts confirmed this. 10. Beginning 8/28/19 Licensed Nursing Staff will monitor wanderguards, document on the Treatment Administration Record (TAR), communicate with the DON and Social Worker regarding residents who display behaviors, and update the Kardex and Nursing Care Plan to reflect new interventions, as needed. The survey team reviewed the TARS, Kardex, and care plans, and interviews with the DON and Nursing staff on all shifts confirmed this. 11. Beginning 8/27/19 Licensed Nursing Staff will implement appropriate interventions such as 1:1 or 15 minute checks when residents listed at risk for wandering display behaviors. Interview with the DON and Nursing staff on all shifts confirmed this. 12. Beginning 8/27/19 documentation of monitoring residents at risk for wandering is a Task in the CNA P[NAME]. Interviews with the DON and CNA staff on all shifts confirmed this. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on the Administrator job description, Quality Assessment and Quality Assessment and Performance Improvement Committee review, policy review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility staff ensured a safe environment for residents placed Resident #38 in Immediate Jeopardy when Resident #38, a cognitively impaired resident with known exit-seeking behaviors, exited the building. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM in the Assistant Director of Nursing (ADON) Office. F-689, F-835, and F-867 were cited at a scope and severity of J. F-689 is Substandard Quality of Care. An extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM and the A[NAME] was validated onsite by the survey team on 8/29/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: The facility's Quality Assessment and Performance Improvement Committee policy revised (MONTH) (YEAR) documented, .This facility shall establish and maintain a .(QAPI) that oversees the identification and handling of quality issues .Adverse Event: an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk there of, which includes, near misses .To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals . The facility's Quality Assessment and Performance Improvement Program policy revised (MONTH) (YEAR) documented, .This facility shall develop, implement, and maintain an ongoing, facility-wide .program (QAPI), designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems .Individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function . The facility's Safety and Supervision of Residents policy revised (MONTH) 2007 documented, .Facility-Oriented Approach to Safety .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A (Quality Assessment and Assurance) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization .When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze to the extent possible . The facility's Administrator Job Description with a revision date of 8/2018 documented, .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Direct various committees of the facility, such as care plan .quality assessment and assurance . Interview with the Administrator on 8/27/19 at 7:05 PM, in the ADON Office, the Administrator was asked if they had a QAPI meeting since the incident of the elopement on 8/20/19. The Administrator stated, No .we discussed it in daily stand-up meeting .use morning meeting as part of QA (Quality Assessment and Improvement) . The Administrator was asked if the Medical Director had been invited to a daily stand up meeting to discuss the elopement of 8/20/19. The Administrator stated, No, ma'am . Interview with the Administrator on 8/28/19 at 8:32 AM, in the Administrator Office, the Administrator was asked to provide a wanderguard protocol. The Administrator stated, .We do have a Wanderguard Protocol .they (policies) were not located on the shared drive where they should have been, we could not retrieve them because it (policies) had been deleted . Interview with the DON on 8/28/19 at 3:34 PM, in the ADON Office, the DON was asked when were the medical records of wandering residents QA'd. The DON stated, .We just did the QA today . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F689 and F835 2. The facility's QA committee failed to identify appropriate plans of action, and failed to ensure new interventions related to elopement risk and supervision of residents were followed. Refer to F656, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for the residents with wandering behaviors. Refer to F842 The surveyor verified the A[NAME] by: 1. Education was provided to the current staff regarding policies including Elopement; Safety and Supervision of Residents and the Wander Guard Protocol were initiated on 8/27/19 by the Director of Nursing and Assistant Director of Nursing and/or designee. Education included but was not limited to; list of at risk wandering residents, if behavior occurred appropriate intervention was put in place by Licensed Nurse including 1:1 or 15 minute checks. Documentation of monitoring residents at risk for wandering is a TASK in P[NAME] (facility's electronic medical record for CNA documentation) for CNA's (Certified Nursing Assistants). Monitoring with documentation on TAR (Treatment Administration Record) for Licensed Nurses. Communications to DON, SW (Social Worker) regarding residents who display behaviors and updating Kardex (CNA care plan) and the care plan to reflect new interventions as needed. Doors are not to be unlocked without the notification/consent from the Administrator. Documentation of hourly monitoring of doors and documentation of function on audit log. Location of Elopement binder at both nurse's station which include policies and procedure regarding wandering residents. The survey team reviewed the in-service sign in sheets and interviewed staff on all shifts. 2. Beginning 8/27/19 education of staff will occur upon entering facility for their scheduled shift. The survey team reviewed the in-service sign in sheets and interviewed staff on all shifts. 3. Beginning 8/27/19, the charge nurse will monitor the P[NAME] documentation by the CNAs at the end of every shift to ensure P[NAME] documentation was completed including behaviors for ongoing compliance. Any behaviors are documented and a P[NAME] alert will be sent to nursing on the dashboard. The survey team reviewed the audit forms. 4. Beginning 8/28/19, in clinical morning meeting DON, ADON and/or Designee will audit clinical alerts in PCC (facility's electronic medical record) for documentation for compliance daily. The survey team reviewed the audit forms. 5. Beginning 8/27/19, if wandering or any behavior occurs during shift staff will follow current intervention and place resident on 72 hour alert charting which monitor for effectiveness of intervention followed by documentation in PCC. The nurse will update care plan interventions when necessary. The survey team reviewed the charting and interviewed staff on all shifts. 6. Beginning 8/28/19, the Maintenance Director or Housekeeping Supervisor will check the exit doors hourly for two weeks, then decrease to twice daily for two weeks, then daily ongoing. After hour door checks will be completed by RN (Registered Nurse) Supervisor, Charge Nurse, or designee. Checks will be placed on a log verifying that door checks were completed hourly. The survey team reviewed the audit forms and interviewed staff on all shifts. 7. Beginning 8/28/19, daily rounds will be completed by Administration/Department Managers to include monitoring of door alarms for four weeks, then monthly for 3 months. The survey team reviewed the audit forms. 8. On 8/28/19, the kardex and tasks were reviewed and updated as necessary for wandering residents. The survey team reviewed the Kardex and Tasks. 9. Beginning 8/28/19, wander Guard/door/exit audits will be reviewed by Administration in morning meetings Monday through Friday for two weeks. Audits completed on Saturday and Sunday will be reviewed on Monday morning in morning meetings. Wander Guard/Door/Exit audits review will reduce to weekly for four weeks, then monthly ongoing until substantial compliance is achieved. Negative findings will be presented in monthly Quality Assurance meeting to identify any trends or patterns and plans will be reviewed/revised as necessary. If findings indicate non-compliance, audits will resume to the initial schedule and plan will be reviewed and revised as needed. The survey team reviewed the audit forms Noncompliance of F-867 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on the Administrator Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to ensure staff to were monitoring doors to prevent a cognitively impaired, vulnerable resident from eloping from the facility. Resident #38 exited the East Hall Exit Door out into the parking lot and continued toward a heavily traveled street next to the facility. The Administrator's failure to ensure resident safety placed Resident #38 in Immediate Jeopardy when staff failed to supervise and monitor residents with elopement risks and exit seeking behaviors. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM, in the Assistant Director of Nursing (ADON) Office. F-689, F-835, and F-867 were cited at a scope and severity of J. F-689 is Substandard Quality of Care. A extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM, and the A[NAME] was validated onsite by the surveyors on 8/29/19 through review of assessments, policies related to active exit seeking behavior, in-service training records, and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: The facility's Administrator Job Description with a revision date of 8/2018 documented. .Meet with personnel as scheduled, to assist in identifying and correcting problems, and or the improvement of services .Direct various committees of the facility, such as care plan .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . The facility's Director of Nursing Job Description with a revision date of 8/2018 documented, .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Responsible for supervising direction of resident care . Interview with the Administrator on 8/26/19 at 4:42 PM, in the Assistant Director of Nursing (ADON) Office, the Administrator was asked about the incident when Resident #38 eloped from the building. The Administrator stated, .I saw him (Resident #38) at least 30 minutes before .it was reported to me they (staff) were getting him (Resident #38) back in the building .we (Administrative staff) started asking questions found out it was the Licensed Occupational Therapist that had actually intervened to get the patient (Resident #38) out by the road to return to the facility .upon interviewing Licensed Occupational Therapist .she reported that while outside .he (Resident #38) was heading toward the road .she (Occupational Therapist) took a dash toward him (Resident #38) turned around and brought him (Resident #38) to the facility .at that time once he (Resident #38) was back in the facility I started checking the exit doors because it had rained .it was easy to see where the wheel chair tracks from the exit door to the left of the therapy opposite the smoking entrance .when I pushed on the door it opened without the delay egress .I looked up and the light was green indicating the mag (magnetic) lock was unlocked . The Administrator was asked if the alarm sounded. The Administrator stated, No. The Administrator was asked if he was aware a school bus had stopped traffic on the road. The Administrator stated, No. Administration failed to ensure staff supervised and monitored Resident #38 who had wandering and exit seeking behaviors and failed to ensure staff were monitoring exit doors. Refer to F689. Administration failed to ensure staff followed care plan interventions for residents with exit-seeking and wandering behaviors. Refer to F656. The surveyor verified the A[NAME] by: 1. The Administrator will provide ongoing monitoring by reviewing audit sheets for exit doors daily beginning on 8/29/19. The survey team reviewed the audit forms. 2. Administrator will make walking rounds daily Monday-Friday to check exit doors to ensure they are secure beginning 8/29/19. Interview with the Administrator confirmed this. 3. Administrator will complete walking rounds twice daily Monday-Friday. As well as monitoring staff activity to ensure supervision of residents beginning 8/29/19. Interview with the Administrator confirmed this. 4. Beginning 8/29/19 the Administrator will audit P[NAME] (Plan of Care) documentation in PCC (facility's electronic medical record) in regards to Behaviors/Wandering for Four Weeks. Weekly ongoing to ensure staff is monitoring behaviors. Interview with the Administrator confirmed this. 5. Beginning 8/29/19 the Administrator will audit TAR's for residents who are at risk for wandering to ensure that licensed nurses are checking wanderguards daily. Audits will be daily Monday-Friday for Four Weeks, then weekly thereafter, until substantial compliance is achieved. Interview with the Administrator confirmed this and the survey team reviewed the audit forms. 6. Beginning 8/29/19 the Administrator will conduct walking rounds daily to interview staff to ensure staff has retained education pertaining to residents with exit seeking/ wandering behaviors, regarding elopement, safety of wandering residents. Rounds will be twice daily, this measure will be ongoing. Interview with the Administrator confirmed this. 7. Starting 8/29/19 any negative findings will be presented in monthly Quality Assurance meeting to identify any trends or patterns and plans will be reviewed/revised as necessary. Interview with the Administrator confirmed this. 8. If findings indicate non-compliance from 8/29/19, audits will resume to the initial schedule and plan will be reviewed and revised as needed. Interview with the Administrator confirmed this. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.