Every finding on record at Diversicare of Oak Ridge

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to document resident incidents/unusual occurrences in the clinical record, at the time of occurrence for 2 Residents (Residents #7 and #8) of 8 residents reviewed for abuse or neglect. The facility failure resulted when it reported intimate contact between Residents #7 and #8 occurred unexpectedly on or about 10/7/2025, to the state agency as potential abuse. The findings include: Review of the facility policy Purpose of the Patient Record (undated) revealed .Clinical records are maintained to provide complete and accurate patient information for continuity of care. The record shall contain sufficient information to identify the patient clearly, justify diagnosis and treatment .document results accurately .The clinical record shall contain the documented course of the patient's health care and provide a medium of communication amongst health care professionals involved in the patient's care . Medical record review showed Resident #7 was admitted to the facility 3/7/2024 with diagnoses including Schizoaffective Disorder Bipolar Type, Dementia in Other Diseases Classified Elsewhere, Moderate, Generalized Anxiety Disorder, History of Transient Ischemic Attack, and Adult Failure to Thrive. Review of the Quarterly Minimum Data Set, dated [DATE] showed Resident #7 scored 3/15 on the Brief Interview of Mental Status Examination (BIMS) which indicated Resident #7 was severely cognitively impaired. Resident #7 required assistance of one person for activities of daily living. Medical record review showed Resident #8 was admitted to the facility 6/14/2024 with diagnoses including Unspecified Peripheral Vascular Disease, Unspecified Dementia with Mood Disturbance, Bipolar Disorder, Type 2 Diabetes and Adult Failure to Thrive. Review of the Quarterly MDS dated [DATE] showed Resident #8 scored 9/15 on the BIMS and was severely cognitively impaired. Resident #8 required assistance of one or two- persons for activities of daily living. Review of the facility investigation, witness statements, and social work documentation dated,10/7/2025 showed on that date, Residents #7 and #8 were found engaged in a sexual encounter in an empty room, by facility floor staff, who reported the incident as potential resident versus resident sexual abuse to facility administration. The facility launched an investigation after both residents were separated and protective monitoring initiated. The incident was reported to the State Agency and all required authorities. Review of social work documentation contained in the facility investigation showed the relationship between the elders was consensual, and the responsible parties for Residents #7 and #8, had given consent to the relationship between the residents prior to the reported incident. Social work documentation contained in the investigation also included detailed notes of interviews of both residents which indicated both were willfully involved in a romantic relationship and had been so for several months prior to the incident. Review of facility clinical records showed on the date of the incident, no documentation of the incident itself as reported to facility administration was included in nursing notes or other clinical documentation by staff who made first contact with the residents. Nor were the facility's immediate responses to the incident documented. Medical progress notes dated 10/7/2025, showed the facility medical staff conducted detailed physical examinations of both residents in response to the incident, documented pertinent findings, and ruled out injury or abuse of either resident. All encounters between the residents after 10/7/2025 were noted in the nursing medical records reviewed and care plan for both residents was updated in response to the incident to accommodate privacy during sexual encounters for both. The incident in question was not documented in clinical records by nursing or social work staff for either resident at the time of occurrence, though facility findings/interventions performed in response to the incident were documented/referenced in records documented by the facility Medical Director and Psychiatric Nurse Practitioner and care plans for both Residents were updated in response to the incident. During interview on 7/23/2026 at 3:55 PM the Director of Nursing confirmed that the facility internal investigation as reviewed was completed for incident on 10/7/2025 between Resident #7 and Resident #8. However, the facility medical record documentation of the incident as reported lacked nursing notes or social work notes related to the incident and immediate responses to it, and therefore the medical record of the incident was incomplete.

Based on observations and interview the facility failed to maintain prepared foods in the dietary department within safe serving temperature ranges during the lunch meal service on 5/27/2025. The findings include: During an observation of the dietary department on 5/27/2025 at 12:45 PM, revealed the facility gas range and commercial dish washer was inoperable due to the gas supply being shut off for a gas leak. Foods were heated in the facility's electric convection oven, placed into disposable aluminum pans, which were then placed inside the steam table pans for temperature management during the meal service. Continued observation of the meal service during the latter third of the tray pass, revealed the steam table controls were set to the high setting. The food temperatures were checked with the facility's calibrated thermometers and revealed the following Fahrenheit (F) temperature readings: Baked chicken 107 degrees, barbeque pork 120.4 degrees, pureed corn 108 degrees, and the cooked spinach 104 degrees. The remaining 2 items on the tray line were maintained at safe temperature ranges, the regular cooked corn was 143 degrees, and the mashed potatoes were 153 degrees (unsafe food holding temperatures are between 41-135 degrees F). During an interview on 5/27/2025 at 12:55 PM, the Certified Dietary Manager (CDM) stated the food temperatures were checked prior to the start of the lunch meal service and had not been monitored during the remainder of the meal service. The dietary manager stated due to the facility's gas leak, the kitchen had utilized the electric convection ovens to heat foods and had placed the prepared food items into the disposable aluminum pans. The disposable pans were placed inside the aluminimum or steel pans and then placed on the steam table which reduced the amount of cooking equipment that had to be washed due to the facility dishwashing system and hot water being rendered inoperable by the loss of the gas supply. The CDM confirmed the facility failed to maintain safe food temperatures for the entirety of the lunch meal service.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #1) by Resident #2 of 14 residents reviewed for abuse. The findings include: Review of the facility's abuse policy dated 1/2019, revealed .Purpose: To prohibit and prevent abuse .includes .sexual abuse .Sexual Abuse: Nonconsensual sexual contact of any type with a resident/patient . Review of the medical records and facility investigation documentation revealed on 2/1/2025 sexual contact between 2 residents occurred when Resident #1 and Resident #2 were observed in Resident #2's room having sexual intercourse. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Schizoaffective Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 4 on the Brief Interview of Mental Status (BIMS) which indicated severe cognitive impairment. The resident ambulated independently and required supervision or set up assistance of 1 person with activities of daily living (ADL's). Review of a Medical Director note for Resident #1 dated 2/3/2025, revealed .[Resident #1] caught in another patients room voluntarily actively engaging in sexual behavior Patient was reportedly happy and without any signs of abuse .No signs of trauma No signs of rape . Medical record review of a current care plan for Resident #1 revealed .Sometimes I demonstrate sexually inappropriate behaviors exhibited by inappropriate touching .Initiated 03/12/2024 Revision 02/03/2025 .As a diversion, offer me something else I like .attempt to redirect, reminding me that the behavior is not appropriate . Continued review revealed Resident #1 did not have a care plan and no documentation of a discussion with Resident #1's family/representative to include consensual sexual activity in the facility. Review of Social Services notes for Resident #1 revealed .2/04/2025 .she [Resident #1] states she is doing well today she feels safe and is going to an activity soon .2/05/2025 .spoke with [Resident #1] she is having a good day feels safe .getting ready to join an activity. Discussed if she had anything happen this past weekend that has upset her and [Resident #1] states, no I had a good weekend. no concerns . Review of the psychiatric note for Resident #1 revealed .2/05/2025 .[patient] able to make needs/desires known [and] physically act on needs/desires .excellent non-pharmacological intervention for mood .[patient] interviewed via telehealth [with] no [complaints of] mood sleep or appetite once again denies [signs/symptoms] trauma/fear, no [complaints of] staff or fell ow residents. Dementia appreciated however can make needs known . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Depression. The resident was discharged to the hospital on 2/6/2025. Continued review of the medical record revealed no documentation of a discussion with Resident #2's family/representative regarding consensual sexual activity in the facility. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #2 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment. The resident required assistance of 1 person with ADL's. Review of the facility investigation revealed on 2/1/2025 at 7:45 PM, Certified Nursing Assistant (CNA) C entered Resident #2's room and found Resident #1 having sex with Resident #2. During observation and interview on 2/10/2025 at 11:40 AM, Resident #1 stated .I make friends, and we go outside and talk .I don't have a boyfriend .yeah [feels safe] .no [no abuse including sexual] .I like to walk around I don't stay in my room .I just like it here I'm happy here . Observation showed the resident calm, smiling, and pleasant to talk to. During an interview on 2/10/2025 at 9:45 AM the Administrator stated .it was completely consensual .the Gero psych [geriactric psychiatric Nurse Practitioner] in her notes indicated that she's had [Resident #1] on case load and she has encouraged her to have a male friend the resident has a history and a desire to be friendly with others .the CNA didn't expect to see what she saw .the reason it was reported was because of [Resident #1's] BIMS being low .when the CNA walked in it was stopped .I interviewed [Resident #2] that night .I said I'm trying to find out if anything happened tonight unusual and he said no .I asked him if he had sexual relations and he denied it .I asked if he ever had sexual relations and if they didn't want to what would you do and he said I'd stop .he was calm he wasn't anxious or anything like that .I determined I did not have a perpetrator on my hands .he said three different times that he would know when to stop if someone didn't want to .when this surveyor asked what would you do if [Resident #1] walked into [Resident #2's] room he stated we would separate them .we are concerned because she has a low BIMS . During an interview on 2/10/2025 at 11:00 AM, the Social Services Director stated .I talked to [Resident #1] Monday [2/3/2024] morning .and then Tuesday and Wednesday also .I just asked did she feel safe, she did .she told me she had a good weekend .I asked her if anything happened over the weekend that may have bothered her or anything and she said no .she's still going with her friends to the dining room and joining activities .she's doing just fine . During a telephone interview on 2/10/2025 at 12:25 PM, Resident #1's sister stated .they [the facility staff] said that [Resident #1] wasn't in her room and they went looking for her and found her in [Resident #2's] room in the same bed and her pants was down .I don't know if she could consent to something like that I just don't know I have no clue because I don't know what stage of dementia she's in she speaks for herself .I've seen her since and she doesn't seem to be scared .oh yeah I do think she is safe there [facility] . During an interview on 2/10/2025 at 2:20 PM, Licensed Practical Nurse (LPN) A stated .[CNA C] had came out of [Resident #2] room and said [Resident #1 and Resident #2] were getting it on [sexual intercourse] .I [LPN A] went into the room and I saw [Resident #2] pulling up his pants and [Resident #1] was in the bed closest to the door with her pants up and the top of her pants was kind of rolled down to the bottom area of her belly she did have a shirt on her brief was on the floor between the two beds .[Resident #2] was on the left side of the bed he had his shirt and his hat on and he was pulling his pants up and he had underwear on .from the time [CNA C] walked out to the time I walked in was about 45 seconds .[Resident #1] was in a pleasant mood relaxed she questioned why we were taking her to her room .[Resident #2] was rambling on he was upset that we were taking her out of the room .I couldn't tell you what [Resident #1] is actually capable of mentally .she is kind of forgetful and wonders .[Resident #2] knows right from wrong he takes care of himself . During an interview on 2/11/2025 at 6:35 AM, CNA C stated .I was doing my rounds on the 400 hall the door was closed and when I opened the door I witnessed 2 people having sex .I saw someone bent over the bed while [Resident #2] was standing behind someone having sex I seen the motions .I went out of the room got the nurse and we went back to the room immediately then I seen it was [Resident #1] from the 300 hall [Resident #2] was pulling up his pants and [Resident #1] was laying on the bed she had a shirt on and her pants was around her ankles and her brief was in the floor I told them to get their clothes on and I removed her and took her back to her room . During an interview on 2/11/2025 at 8:00 AM, the Psychiatric Nurse Practitioner stated .[Resident #1] had sex with [Resident #2] .[Resident #1] has a history of seeking out male attention .despite her cognitive shortcomings [Resident #1] can make needs known and act on needs .when I assess her if you were to grab her and she didn't want you to she would push you away because she knows .however she is confused she has mental pathology with dementia superimposed upon that pathology .she can make a decision about anything you can't force anything on [Resident #1] .I asked her .if somebody hurt her and she said no and she was just as placid as you can be .I did ask her again and she said she was fine she had no problems .if both parties are consensual in a sexual act then it would not be considered abuse in regards to this patient .

Based on facility policy review, medical record review, facility investigation documentation review, observation, and interview, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 residents (Resident #1 and #7) and verbal abuse by a resident for 2 residents (Resident #7, and #9) of 22 residents reviewed for abuse. The findings include: Review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed .Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse: includes, but is not limited to, hitting, slapping, punching, biting and kicking .Verbal abuse .includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend . Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses including Metabolic Encephalopathy, Altered Mental Status, Dementia without Behavioral Disturbance, and Cognitive Communication Deficit. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact, with no noted behaviors during the assessment period. Review of the Nurse's Note for Resident #1 dated 6/11/2024 at 10:45 AM, revealed .this nurse informed by CNA [Certified Nursing Assistant] [F] that another resident [Resident #3] had informed her she seen another resident [Resident #2] enter [Resident #1's] room and then she heard [Resident #1] yelling 'don't you hit me!' .[Resident #1] then told this nurse a man [Resident #2] came into his room had hit him in the face .Both [Resident #1] and the other witness [Resident #3] identified the same man [Resident #3] as the one that came into his room . Review of the medical record revealed Resident #2 was admitted to the facility 6/10/2024 at 6:40 PM, and discharged on [DATE] at 12:52 PM, with diagnoses including Insomnia, Depression, Psychosis, Metabolic Encephalopathy, Altered Mental Status, and Dementia without Behavioral Disturbance. Review of a discharge MDS assessment for Resident #2 dated 6/11/2024, revealed discharge assessment-return anticipated. A BIMS assessment was not completed. Behaviors of physical symptoms directed towards others and verbal symptoms directed toward others occurred 1 to 3 days during the assessment period. Review of the Nurse's Note for Resident #2 dated 6/11/2024 at 7:41 PM, revealed .at approximately 10:30 AM, res [resident] went into another residents' room . [Resident #2] left the room after this incident. [Resident #2] was placed on 1 on 1 until his departure .NP [Nurse Practitioner] was contacted and gave order to send res. out to [hospital] for psych [psychiatric] eval [evaluation] . Review of the facility investigation dated 6/11/2024, revealed Resident #3 (now discharged ) witnessed Resident #2 go into Resident #1's room and slam the door, she heard someone say, What are you doing in here? and Don't hit me. She then witnessed Resident #2 come out of the room. She reported this to CNA F who went and spoke to Resident #1. Slight redness was present on Resident #1's cheeks. Resident #1 confirmed he was okay and was not afraid. Resident #2 was placed on continuous 1 to 1 staff observation. Both residents' physician was notified, and an order was received to send Resident #2 to the hospital for evaluation and he was admitted . Resident #2 was confused and when asked why he had struck Resident #1 he replied, I thought he stole me. When asked why he went into Resident #1's room he stated, that was my room. I want to leave. Mental health services were notified for follow up with Resident #1. Review of a facility documented interview with Resident #3 dated 6/11/2024, revealed .[Resident #3] states she observed [Resident #2] enter [Resident #1's] room. She then heard someone say, 'What are you doing? Get the hell out of my room.' She then heard someone say, 'don't hit me.' She stated that [Resident #2] slammed the door and walked out of the room . During an interview on 8/12/2024 at 11:10 AM, the Rehabilitaion Director . stated I was here that day [6/11/2024], but I did not witness the incident [Resident #1] came to therapy after the incident .He [Resident #1] did understand that the other resident [Resident #2] was confused and was not in his right mind .he [Resident #1] wasn't tearful, he did want to talk about the incident, but he was not emotional .he wasn't weepy he wasn't withdrawn. He was not afraid . The Rehabilitaion Director stated there were not visible signs of injury to Resident #1 and the resident did not verbalize any pain from the incident. During an observation and interview on 8/12/2024 at 11:25 AM, of Resident #1, in his room, showed the resident lying on the bed he was awake, alert, with no signs of distress.Resident #1 stated .I'm doing alright . When asked about the incident he stated .he [Resident #2] knocked on my door like the staff do .I was standing over there he came in and said what are you doing with my wife in your bed. I said I don't have your wife, no one is in the bed . Resident #1 stated Resident #2 struck out at both of his cheeks.no it didn't hurt, I just couldn't figure out why he thought I had his wife in my bed .he didn't draw blood or anything like that, and like I said it didn't hurt. It kind of stunned me that he had hit me .no I wasn't scared, and I am not scared now .he wasn't in his right mind .there was a lot of people coming in and out of here to check on me . During an interview on 8/13/2024 at 11:45 AM, the Certified Occupational Therapy Assistant stated .I saw him [Resident #1] in the afternoon somewhere between 1:00 PM and 2:00 PM, (incident occurred approximately 2 1/2 hours prior) and there was no evidence that he had been smacked on his face. There was no redness, no bruising, no abrasions .he did talk about the incident, he just expressed what had happened .he wasn't distraught, fearful, or emotionally upset, he simply told me what happened . During an interview on 8/13/2024 at 2:20 PM, the Previous Administrator stated basically Resident #2 was confused and didn't know where his room was. He entered [Resident #1's] room thinking it was his own and may have popped [slapped] [Resident #1] twice once one each cheek. There wasn't any lasting redness or bruising .he confirmed to me that the gentleman did strike him, so I did feel like it was willful intent and abuse had occurred. He did not report being afraid, and I saw no signs of fear, tearfulness or being withdrawn. During an interview on 8/14/2024 at 12:15 PM, Licensed Practical Nurse (LPN) U stated .[CNA I] came and told me that [Resident #3] reported to her she had seen a resident enter [Resident #1's] room and heard [Resident #1] say don't you hit me .No [Resident #3] did not witness the altercation .there was no witnesses .I immediately went to the room, [Resident #2] had already left the room .I spoke to [Resident #1] and he told me that a man [Resident #2] had come in his room and hit him in the face 2 times .his face is always a little red .he didn't have any abrasions or bruising .[Resident #1] didn't understand why the resident had come in his room and hit him .he wasn't tearful or crying, he wasn't withdrawn .I did a head to toe assessment on [Resident #1] and there were no injuries .the slight redness was gone in just a very few minutes less than 30 minutes, and the areas never bruised .when I checked on him at the time and within minutes he was calm, he wasn't scared, tearful or anything .we took [Resident #2] to the day room and a CNA stayed with him 1 on 1 until the ambulance transported him to the hospital .[Resident #2] .was confused, I don't think he knew what he had done . During an interview on 8/14/2024 at 12:35 PM, CNA I stated .I went in [Resident #3's] room to get her lunch tray. She told me that the man across the hall was saying don't hit me .she didn't see the altercation, she just heard what [Resident #1] said .I went in the room and checked on [Resident #1] and no one was in the room with him .I asked [Resident #1] if anyone had been in his room and he said yes that a man had come in his room and hit him in the face .he was barely red in the face under both eyes .I went to the desk and got the nurse .[Resident #2] .had just admitted the evening before and he was really confused .I had not seen any aggressive behaviors from him . During an interview on 8/14/2024 at 3:25 PM, the Medical Director stated .[Resident #2] was very confused and moody .he was here for a very short time and was sent out .[Resident #1] didn't have any bruising or fractures .he has mild dementia .He had no pain, no headaches, no physical harm .emotionally because of his demeanor he is forgetful and a forgiving guy he forgot about it very quickly .he remains social .in my professional opinion he did not suffer any physical harm or emotional harm . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses Dementia with Behavioral Disturbance, Psychosis, Chronic Kidney Disease, Sequela of Cerebral Infraction, Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder. Review of the Nurse's Notes for Resident #7 dated 1/9/2024 at 8:23 PM, revealed .Resident .was the recipient of verbal and physical aggression this evening from another resident [Resident #8] .residents were separated, and safety was ensured. Resident was interviewed a few minutes after event by Administrator and was unable to recall the event. She shows no signs of fear . Review of a facility investigation dated 1/9/2024, revealed the event was witnessed by CNA S. CNA S reported the allegation of verbal and physical abuse to LPN L. There were no physical injuries to Resident #7 or Resident #9. Resident #7 reported she did feel safe and was unable to recall the incident. The facility facilitated a room change since her roommate [Resident #8] is also the aggressor. The Medical Director was the physician for all 3 residents involved and was notified. Resident #8 was placed on observation by the staff. She was not to have a roommate on 1/9/2024 and was referred for mental health services. Residents #7, #8, and #9 were sitting in the dayroom prior to supper meal delivery. Staff members were also nearby but were unable to determine what the residents' conversations were about. Resident #9 became louder in her conversation and Resident #8 told her to shut up. Resident #8 began to wheel herself out of the dayroom as staff responded to the situation. However, Resident #8 turned around and told Resident #7 to shut up and struck Resident #7's hand with her own closed fist. Review of the Physician's Progress Note for Resident #7 dated 1/10/2024 at 3:06 PM, revealed .[Resident #7's] hand was smacked yesterday [1/9/2024] by another resident [Resident #8]. Residents were immediately separated and pt.'s [patient's] hand showed no sign of injury. Pt. seen this AM, she is in bed, now in new room. She is alert and in good humor this AM. Oriented to name only, no recall of events, did let me look at both arms and hands-no bruising, swelling, redness noted. She denies any pain .No changes required . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses included Dementia with behavioral Disturbance, Psychosis, Major Depressive Disorder, Anxiety Disorder, and Senile Degeneration of Brain, Cerebellar Ataxia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 did not have a BIMS or a staff assessment completed. Review of the Nurse's Note for Resident #8 dated 1/9/2024 at 8:15 PM, revealed .this resident exhibited aggressive verbal and physical behavior toward others this evening. There was no injury to anyone. Resident does not recall the event minutes afterward. Resident is under staff observation for her own safety and the safety of others at this time . Review of the Physician's Note for Resident #8 dated 1/10/2024, revealed .requested to see Pt. with incident yesterday of smacking other resident [Resident #7] on the hand. Staff report other resident [Resident #9] sitting near her and told her to 'shut up.' There was no physical injury noted to either resident at the time. Residents were separated. Pt. seen this AM. She is alert, has no recall of the incident, 'I don't remember that.' She is calm with no indication of aggressive behaviors now. She has been separated from the other residents. I see no medication changes required today. Pt. with known history of dementia. I don't think she recalls the incident and does not have the insight or judgement to discuss it further . Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 9 on the BIMS assessment which indicated the resident had moderately cognitive impairment. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses included Dementia with Behavioral Disturbance, Anxiety Disorder, Severe Protein-Calorie Malnutrition, and Vertigo. Review of the Nurse's Notes for Resident #9 dated 1/9/2024 at 8:20 PM, revealed .Resident #9 was the recipient of verbal aggression from another resident this evening. Residents were separated and safety ensured. [Resident #9] was interviewed but was unable to recall the event just a few minutes later. Resident displays no sign of fear . During an interview on 8/12/2024 at 10:55 AM, Resident #7 stated when asked how she was I'm just [NAME]. When asked about the incident she stated do what? I am not sure what you are talking about . Additional details about the incident were given to the resident but the resident had no recall of anyone mistreating her, yelling at her, or smacking her hand. During an interview on 8/12/2024 at 11:05 AM, Resident #8 stated when asked about the incident I don't remember that .I don't remember yelling or smacking anyone .I don't know what you are talking about . During an interview on 8/12/2024 at 1:40 PM, CNA T stated .it was at the end of the shift [Resident #8] and[ Resident #7] were roommates both were very confused. They were in the day room the television was loud. [Resident #7] was really confused, and she kept telling [Resident 8] she was going to call the police on her. There are two tables in there and there were several residents in there. I didn't hear her [Resident #8] tell [Resident #9] to shut up, [Resident #8] was starting to leave the table then backed up, [Resident #7] kept saying she was going to call the police, then [Resident #8] just popped [Resident #9] on the hand it wasn't hard, her hand wasn't red at all. [Resident #9] wasn't upset she wasn't crying or tearful, she didn't yell out when she got smacked she didn't act like it even phased her .we pulled [Resident #8] out of the dining room .there was no emotion from [Resident #9] .that made me think anything had happened to her .[Resident #8] and [Resident #7] both were moved to increase the space between them. [Resident #7] .she is sociable, not withdrawn, not fearful, [Resident #8] .hasn't changed any. Neither of them remembered the incident almost immediately. The Administrator .talked to all 3 of the residents and none of them remembered .[Resident #8] did pop her [Resident #7's] hand on purpose .to get her to stop whatever it was she was doing .when we realized she [Resident #8] wasn't going to leave the day room, we started toward them, but we couldn't get to her before she popped [Resident #7] on the hand . During an interview on 8/12/2024 at 1:55 PM, CNA J, stated .several residents were in the day room .I didn't hear [Resident #8] tell [Resident #9] to shut up .I heard [Resident #7] and [Resident #8] talking .before I could get to them, I saw [Resident #8] smack [Resident #7] on the top of the hand. It wasn't hard it was like you would smack a small child's hand .We separated them and [CNA T] took [Resident #8] out of the day room .[Resident #7] wasn't crying or scared or anything like that .she didn't yell or jerk her hand when she was hit, it wasn't a hard hit . During an interview on 8/12/2024 at 4:30 PM, LPN L stated .the CNAs were in the day room .I heard a commotion in the day room, I told the CNAs to separate the residents, and I told the nurse to call the Administrator. [Resident #7] did not have any redness, swelling or bruising to her hand .neither of the 3 residents were upset, no one was crying or tearful, no one was acting fearful . During an interview on 8/13/2024 at 2:20 PM, the previous Administrator stated .the 3 residents were setting at the dining room table .[Resident #8] does have dementia, but I do believe there was intent there .we did substantiate abuse had occurred .

Based on facility policy review, medical record review, and interview, the facility failed to ensure professional standards of practice were followed when transportaion was not provided to outpatient scheduled appointments for 2 residents (Resident #25 and Resident #34) of 6 residents reviewed for transportation needs. The finding include: Review of the facility policy titled, Standards of Practice, undated, revealed .The expectation set forth by .management is that nurses comply with current standards of practice .this includes following orders for outside appointments/referrals .center can arrange transportation if required . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Atherosclerotic Heart Disease, Foot Drop, and Muscle Weakness. Continued review revealed the resident discharged out of the facility with family on 5/13/2024. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of hospital discharge documentation for Resident #25 dated 4/30/3034, revealed the resident's post discharge orders included .scheduled appointments: office visit 5/8/2024 at 2:20 PM .[Cardiology Physician's Group] . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Hypertension, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. Review of an admission MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of hospital discharge documentation for Resident #34 dated 7/25/2024, revealed the resident's post discharge orders included .scheduled appointments: office visit 8/5/2024 at 1:00 PM .[a Brain and Spine Center] . During an interview on 8/13/2024 at 8:55 AM, Resident #34 stated she had to cancel an appointment due to the lack of transportation. Continued interview revealed the facility told the resident after she had canceled the appointment, the facility could have provided the transportation. Further interview revealed, the resident was not told and was not aware the facility could have provided the transportation to the outpatient appointment. Further interview revealed .I would have gone [to the Brain and Spine Center] if I knew they [facility] provided transportation . During an interview on 8/13/2024 at 10:15 AM, the Transportation Director (TD) stated she was not aware of the missed appointments for Resident #25 or Resident #34. Continued review of the TD's transportation log with the TD revealed no documentation of any scheduled or missed appointments for Resident #25 or Resident #34. During an interview and medical record review on 8/13/2024 at 2:18 PM, the Director of Nursing (DON) stated there was no documentation in the resident chart which indicated Resident #25 or Resident #34 had gone to the scheduled appointments. The DON confirmed the facility failed to ensure transportation was provided for the residents to the scheduled outpatient appointments. During an interview and medical record review on 8/14/2024 at 12:20 PM, the Medical Director stated the facility could improve on the follow up of outside appointments related to scheduling and tranportation. Continued interview revealed Resident #25 and Resident #34 had not had any negative outcome or adverse events due to the missed appointments.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to report an allegation of sexual assault to the State Agency within 2 hours as required, for 1 resident (Resident #10) of 22 resident's reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated 1/2019, revealed .To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations .in accordance with Federal and State Laws .Abuse .includes .sexual abuse .Nonconsensual sexual contact of any type with a resident/patient .Reporting/Response .Alleged violations/violations will be reported to the Administrator, designee immediately. Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies .with specified timeframes . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Parkinson's Disease with Dyskinesia, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, and Schizoaffective Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The resident wandered daily during the assessment period. Review of the physician's notes for Resident #10 dated 1/26/2024 at 11:46 AM, revealed .[Resident #10] complained sexual assault happening when she went out over a weekend .says a staff member here .[took] to their house, then led to a shed where she was assaulted, thinks this is was three weeks ago but no evidence she was out of building in looking at nurse notes, she did go to church on wed night .same scenario on tv on a crime show was playing while he [Administrator] talked to her in room [Resident #10's room] this problem is complicated by schizophrenia, she did nto [not] think she was in her own room .There is no evidence the assault happened but she believes it has and is distressed over this . Review of facility investigation documentation revealed the previous Director of Nursing (DON) and previous Administrator became aware of Resident #10's allegation of sexual assault on 1/28/2024 at 4:30 PM (2 days after reported to the resident's physician). Resident #10 .reported to her physician that about 3 weeks ago someone had taken her from the center to a shed and sexually assaulted her . During an interview on 8/14/2024 at 2:50 PM, the Medical Director stated Resident #10 reported she was taken from the facility, was taken to a shed and was sexually abused.in her [Resident #10] mind she was taken to a shed and was sexually abused . During an interview on 8/19/2024 at 1:30 PM, the Administrator stated allegations of abuse were to be reported to the State Agency within 2 hours of the allegation. The Administrator confirmed Resident #10's allegation of sexual assault was not reported to the State Agency within 2 hours as required and confirmed the facility failed to follow the facility's abuse policy related to reporting an allegation of abuse for Resident #10. During an interview on 8/19/2024 at 10:55 AM, the Medical Director stated she notified someone of Resident #10's allegation immediately, and documented what the resident reported in the resident's medical record on the same day the allegation was made (Physician note was dated 1/26/2024 at 11:46 AM). During a telephone interview on 8/19/2024 at 2:02 PM, the previous Administrator stated .I do remember talking to [Resident #10] on multiple times .3 or 4 different times .she had not given me anything of an allegation of abuse, but when she did, I reported it to the state . When asked why he started questioning Resident #10, the previous Administrator stated .I believe someone let me know that her confusion was increasing .I believe that was what started it all .I do know she has reported this similar allegation before . When asked if he recalled the resident's physician, the DON, or a staff member reporting the allegation made by Resident #10, the previous Administrator stated .No .No, I don't remember .

Based on facility document review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #8) of 13 residents reviewed. The findings include: Review of an undated, facility document titled, RN [Registered Nurse] Nurse Assessment Coordinator, revealed .supervises, coordinates and facilitates the timely and accurate completion of the RAI process .ensures accurate and timely MDS assessments according to state and federal regulations . Review of the RAI Manual 3.0 dated 10/1/2023, revealed .the assessment [MDS] accurately reflects the resident's status . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses included Dementia with behavioral Disturbance, Psychosis, Major Depressive Disorder, Anxiety Disorder, and Senile Degermation of Brain, Cerebellar Ataxia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 did not have a Brief Interview for Mental Status (BIMS) or a staff assessment completed. During an interview on 8/19/2024 at 3:00 PM, Registered Nurse (RN) V/MDS Coordinator confirmed the MDS assessment dated [DATE], for Resident #8 did not have a BIMS assessment or staff assessment completed for mental status. She stated .the computer generates which sections should be completed and on a quarterly MDS. C section for mental status should have been completed and it was not .

Based on facility policy review, observations, and interviews the facility failed to provide a homelike environment for 1 resident room (#512) of 7 resident rooms observed for homelike conditions and failed to prevent foul odors for 1 hallway of 5 hallways observed. The findings include: Review of the facility's policy titled, Resident's Rights and Quality of Life, dated 5/1/2012, revealed .It is the policy .that all residents have the right to a dignified existence .A resident has the right .To receive services in a facility environment that is safe, clean, and comfortable . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Pressure Ulcer of Left Heel, Severe Protein-Calorie Malnutrition, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a facility Census List revealed Resident #40 transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 7/24/2024. During an observation of room [ROOM NUMBER] B and interview on 8/13/2024 at 10:36 AM, revealed damaged and peeling dry wall, with an approximately 6-inch x 10.5-inch hole, located behind the bed, and to the right side of the head of the bed. Resident #40 stated the hole in the wall behind his bed was present when he transferred to the room. Resident #40 stated environmental services staff had brought a maintenance staff to his room and showed him the wall .a couple of weeks ago . During a second observation of room [ROOM NUMBER] and interview on 8/15/2024 at 9:40 AM, revealed additional areas of damaged dry wall, above the base board, on the left side of the bed. Resident #40 stated the hole, on the left side of his bed was present when he transferred to the room. During an interview and observation of room [ROOM NUMBER] B on 8/15/2024 at 9:50 AM, with the Administrator and Corporate Regional [NAME] President, the Administrator confirmed the dry wall behind the resident's bed was damaged and confirmed the facility had not provided a homelike environment for Resident #40. During observations of the 600 Wing between room [ROOM NUMBER] and the Wound Care Office on 8/19/2024 at 9:32 AM; at 10:38 AM; and 2:00 PM revealed the presence of a strong, foul odor persisted throughout the observations and was unable to be identified. During an interview and observation with the Director of Nursing (DON) and Administrator while standing in the impacted area of the 600 Wing on 8/19/2024 at 2:15 PM revealed the foul smells persisted. Both the DON and Administrator confirmed the facility had failed to maintain a homelike environment on the 600 wing when fould odors persisted through the wing.

Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to implement appropriate fall interventions to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure placed residents (#74, #253, #149 and #89) in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #74 sustained a shattered Left Acetabulum (the socket of the hipbone) and Simple Fracture of the Left Pubic Ramus (Pelvic fracture) after a fall on 8/2/2023, when Resident #253 sustained a Left Femoral Fracture (break in the thigh bone) after a fall on 7/10/2023, and when Resident #149 sustained a Right Epidural Hematoma (when blood accumulates between the skull and the covering of the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) during a fall on 5/17/2023. Resident #89 was found sitting on floor in front of her chair, she was confused. An Injury noted to Right side of forehead (A small golf size knot). Resident #89's intervention did not help to prevent further falls. None of the interventions addressed the resident leaning forward. The facility also failed to provide adequate supervision to prevent elopement for 1 resident (Resident #252) of 3 residents reviewed for wandering. The facility's failure placed Resident #252 in Immediate Jeopardy when Resident #252 eloped in his wheelchair from the facility on 3/4/2023, for an unknown specified amount of time and was found 187 feet from the facility and 153 feet from the road. The facility failed to provide adequate supervision, safety measures such as fire blanket, smoking apron, and assessments for 7 smoking residents (#202, #61, #16, #48, #55, #78, and #201) of 22 residents reviewed for smoking. The facility's failure to ensure safe smoking practices and a safe smoking environment placed Resident #202, #61, #16, and #48 in an Immediate Jeopardy which had the potential to affect all 99 residents in the facility. The Administrator, and the Director of Clinical Operations were notified of the Immediate Jeopardy for F689 on 9/18/2023 at 6:10 PM, in the conference room. The facility was cited Immediate Jeopardy at F689 (L) which constitutes substandard quality of care. The Immediate Jeopardy began 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated on-site by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Falls, dated 2/2017, showed .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .Newly admitted or readmitted residents are assessed for fall risk .when a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed .the intervention is documented on the care plan and on the caregiver guide .The identified intervention is initiated .Post fall .The patient is physically assessed for injuries .A fall huddle is called to help in investigating circumstances around the fall .The post fall evaluation is completed to assist in developing interventions to prevent future falls .The fall event and intervention is recorded on .patient's care plan and caregiver guide .Implement intervention identified .IDT [Interdisciplinary Team] reviews post fall investigation and summaries the recommendations for interventions . Review of the facility policy titled, Elopement, dated 4/2017, showed .Team members know how to respond to all door/exit alarms .Once Doors/exit alarms are activated a resident search is completed ensuring there is no missing resident .When an elopement occurs .After the resident has been found complete a thorough evaluation of resident's physical condition and psychosocial wellbeing. Provide medical intervention as needed .Document condition notifications and times of actions deployed . Review of the facility's policy, Safe Smoking, dated 11/1/2016, revealed .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents .To assess the ability to smoke safely and determine any measures needed to protect residents from possible self-inflicted injury due to smoking .Any resident who identifies themselves as desiring to smoke .will be assessed for safety related to smoking .This assessment will be reviewed and updated with any change of condition .The results of the safety evaluation will drive the care plan interventions related to safe smoking .A resident may be re-evaluated for safety needs if there is an observed change in their ability to smoke safely .Tobacco materials (cigarettes/cigars .) themselves, in addition to fire igniting materials, may have increased control or be removed if smoking policy violations have occurred or as general safety policy for all residents .For the benefit of our non-smoking residents, smoking residents may only smoke in the designated Smoking Area at the center .Supervised smokers can only smoke with a staff member present in the smoking area .Various types of protective equipment are to be available in each center .Protective equipment may include fire blankets at each designated smoking area and smoking aprons for individuals assessed as requiring this safety equipment .Each designated smoking area is provided with ashtrays made of noncombustible material and safe design . Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Unspecified Fracture of the Left Acetabulum, Muscle Weakness, Abnormalities of Gait and Mobility, Aphasia [communication disorder], Hypertension, Anxiety, Anemia, Cognitive Communication Disorder, Chronic Obstructive Pulmonary Disease, Cirrhosis of Liver, Chronic kidney Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure. Review of Resident #74's Lift Transfer Evaluation dated 6/27/2023, showed .Can resident/patient safely transfer independently or with oversight only .No .Transfer/Walking Belt x 1 team member is required . Review of Resident #74's Clinical Health Status Evaluation dated 6/27/2023, showed .Expressive aphasia present .Transfer .Physical assistance required .Fall Risk Factors . Impairment in gait or balance .Yes . Impairment in lower extremity strength .Yes .Any Yes answer indicates Fall Risk - Proceed to Care Plan . Review of Resident #74's comprehensive care plan dated 7/21/2023, showed .The resident is at risk for falls r/t [related to] weakness, hx [history] of falls, unsteady gait, need for assistance with ADLs .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs .Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as PT [physical therapy], OT [occupational therapy] . Review of Resident #74 nurses progress note dated 7/21/2023, showed .He has confusion episodes, alert & [and] oriented x [times] 1. He is out of bed sitting comfortably in his wheelchair. Requires x2 max [maximum] assist with transfers. He uses wheelchair for mobility .Call light within reach . Review of Resident #74's admission Minimum Data Set (MDS) dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. He required extensive assistance of 1 person for bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had no falls prior to admission. Review of Resident #74's nurses' progress note change of condition dated 7/27/2023, showed .Situation: Resident laying in the floor at the bottom of the bed skin tear to middle of the back .Resident stated he fell out of his wheelchair trying to move to the other side of the bed .educated resident to use the call light for assistance . Review of Resident #74's Post Fall Review dated 7/27/2023, showed .7/27/2023 .15:00 [3:00 PM] .Chair to floor .Location of fall .at the bottom of the resident bed .Resident stated he fell out of his wheelchair trying to move to the other side of the bed .Physical evaluation .Skin tear .Not witnessed .Educated resident to always use call light for assistance with 2 skin tears .Skin tears treated and orders written .Therapy will complete wheelchair use and safety teaching with resident and will assess WC [wheelchair] for safety and possible addition of anti-roll backs [used on wheelchair to prevent a wheelchair from rolling backwards and helps prevent falls] . Review of Resident #74's comprehensive care plan showed an update on 7/28/2023, .Fall 7/27/23 [2023] . Therapy will complete wheelchair safety teaching . Review of Resident #74's Occupational Therapy Treatment Encounter Note dated 7/28/2023, showed .Precautions .impaired safety awareness/impulsive .COTA [Certified Occupational Therapy Assistant] instructed patient on how to properly maneuver w/c, lock/unlake [unlock] brakes and navigating throughout environment with patient demonstrating fair carryover. Falls prevention education provided and importance of reaching out to nursing via call light when he is ready to go to bed . Review of Resident #74's Physical Therapy Treatment Encounter Note dated 8/1/2023, showed .Bed Mobility . Supervised .Transfer . SBA [stand by assist] .Assistive Device During Transfers .Two wheeled walker . Review of Resident #74's fall documentation (incident report) dated 8/2/2023 at 5:20 AM, showed .Resident reported fall in bathroom. C/O [complaint of] pain to left hip. Knot noted to outer hip upon assessment. New order given to send to ER for evaluation and treatment .Resident reported to PT [physical therapy] that he fell in the bathroom . Review of Resident #74's Physical Therapy Treatment Encounter Note dated 8/2/2023 at 11:32 AM, by Physical Therapy Assistant (PTA) #2 showed .Patient reports left hip pain 10/10 [pain scale of 1-10, 1 being least pain, 10 being worst pain] with any movement. Hip is bruised and swollen .patient reports he fell in bathroom [undetermined date/time by facility] .Information reported to nursing .Nurse Practitioner [NP] evaluated patient and sent to hospital .Unable to actively participate with therapy intervention secondary to pain . Review of Resident #74's change of condition nurse's progress note dated 8/2/2023, showed .Resident reported to day shift that he fell .Complaints of pain to left hip, discoloration to affected area .NP notified and assessed pt .Order received to send to ER [time unknown] . Review of Resident #74's NP visit note dated 8/2/2023 at 12:27 PM, showed .Called to room. Pt. c/o acute lt. [Left] hip pain. He reports he fell in the bathroom- he is found in bed. Nursing and PT staff are present. He has c/o severe pain to lt. hip with attempts to move him. He has knot to lt. outer hip. I believe he will need ER eval rather than attempting in-house x-ray here. informed patient, nursing and PT. all in agreement .acute Left hip pain self-report of unwitnessed fall in bathroom .[Resident reported 1-2 CNAs assisted him to the bathroom and he fell off the toilet and was assisted back to bed by 1-2 CNAs] The facility was unable to provide an investigation for this incident to determine what happened Resident #74. Review of Resident #74's Hospital discharge summary dated 8/15/2023, showed .Hospital course .Report noted .left acetabulum .as well has stable fracture to the .left ramus .extensive hemorrhagic material near left anterior acetabulum .Orhto [Orthopedic] was consulted and recommended nonop [non operative] management with plans for post ambulation films to reeval [re-evaluate] stability . Resident #74 sustained the fracture while at the facility. Review of Resident #74's comprehensive care plan showed an update on 8/29/2023, for .Place on contour mattress to assist in not rolling out of bed [The intervention was added to the care plan 13 days after he fell on [DATE] or 8/2/2023 (date unknown) and the resident fell in the bathroom not in the bed] . The intervention of the contour mattress was not an appropriate intervention for the fall. During an interview and observation of Resident #74 on 9/7/2023 at 9:25 AM, the resident stated he was lying in bed and had a broken hip. The resident's bed was elevated, his call light was lying on top of the nightstand beside of his bed and not in reach of the resident. During an interview on 9/11/2023 at 1:47 PM, Occupational Therapy Assistant (OTA) #1 stated she had provided wheelchair teaching with Resident #74 .we went over calling out when he needs help .and wheelchair safety .falls prevention education was provided .reaching out to nursing via call light when he is ready to go to bed .he had declined since the second fall reported on 8/2/2023 . She confirmed no modifications were made to the wheelchair (the anti-roll backs) at the time of the screen after the fall on 7/27/2023, the anti-roll backs were recommended as a result of the screen. During an interview on 9/11/2023 at 3:08 PM, PTA #2 stated he did not think Resident #74 could have gotten himself out of the bathroom floor after the fall reported on 8/2/2023 . PTA #2 stated Resident #74 informed him he fell in the bathroom (8/1/2023 or 8/2/2023 date of fall unknown). During an observation on 9/12/2023 at 8:54 AM, Resident #74 was lying in bed, call light was hanging on the wall, not within reach. During an interview and observation on 9/12/2023 at 8:57 AM, in the resident's room the Director of Nursing (DON) stated Resident #74 is a fall risk .oh absolutely .we did move him closer to the nurse's station [moved 40 or 41 days after the fall on 8/1/2023 or 8/2/2023 (the actual date of fall is unknown)] . The DON confirmed during the observation, the call light was not in reach and stated .it appears to be hanging on the wall . During an interview on 9/12/2023 at 1:45 PM, LPN #5 stated Resident #74 was a fall risk. She stated interventions in place to prevent falls included .bed in low position [not an intervention on Resident #74's care plan] .call light in reach .reminders .frequent checks [not an intervention on Resident #74's care plan] .I educated him to be sure to always use his call light for assistance .and somebody else put in there [on the post fall evaluation] and therapy will assess .possible anti-rollbacks . She confirmed no alert charting (increased period of charting done after an incident) had been completed for 72 hours after the fall . The LPN stated when therapy does a screen after a resident has a fall, .they normally don't come back and consult with us .we don't get to see therapy's notes . During a telephone interview on 9/12/2023 at 6:11 PM, LPN #10 stated .the fall interventions in place for Resident #74 were .just making sure his call light was in reach, make sure he's changed and didn't get up to go to the bathroom and stuff, making sure his urinal was in reach, and keeping a check on him . LPN #10 stated .they [staff] didn't know when he fell we [nightshift] just got stuck with the incident report .we never found him in the floor .I was aggravated that I had to do the incident report . She [LPN #10] stated she had never assessed the resident after the fall. She stated .when therapy went to get him .and he complained about hip pain . they noticed .bruises . During an interview on 9/13/2023 at 10:08 AM, LPN #5 confirmed she was working dayshift on 8/2/2023. She administered [Resident #74] his medicine at this time he did not complain of pain. LPN #5 stated therapy entered his room and the resident complained of pain. LPN #5 stated, PTA #2 entered the resident's room and PTA #2, LPN #5, and the NP assessed the resident. The resident's left side was swollen and bruised, and his hip was bruised. The resident's entire left side was swollen and bruised in his hip area. The resident was immediately transferred to the hospital. During an interview on 9/13/2023 at 1:36 PM, LPN #12 stated Resident #74 had been assessed as a high risk for falls on admission to the facility and did not have individualized fall prevention interventions developed. During an interview on 9/13/2023 at 3:27 PM, the Administrator stated the facility process falls were to be addressed by the .IDT [interdisciplinary] team .so I have a morning stand up .clinical stand up .currently [LPN #12/falls nurse] .to ensure that the incident is completed appropriately that the investigation is completed thoroughly that an appropriate plan of care is implemented and we document what we did .we discuss it among the team members .we discuss did they slip, did they trip, what exactly happened . During an interview on 9/13/2023 at 3:35 PM, with the Administrator, the fall for Resident #74 was reviewed. The Administrator revealed he had not interviewed Resident #74 after his fall in the facility on 8/1/2023. Interview revealed he had not made any inquiries about what had actually occurred causing Resident #74 to sustain major injuries with a shattered Acetabulum (hipbone) and fracture pelvic bone. Continued interview revealed the Administrator was not aware Resident #74 was put back to bed from the floor by 2 unidentified staff members, with the help of a mechanical lift. Interview revealed the Administrator was unaware the resident was not assessed from the time of the fall until the rehab staff discovered his injury due to pain on movement and a large amount of bruising at 10:00 AM on 8/2/2023. The Administrator confirmed Resident #74 was left in an extremely unstable condition from the time of the fall until he was admitted to the hospital after 11:30 AM the following day. During a telephone interview on 9/14/2023 at 10:37 AM, the NP confirmed .he [Resident #74] fell .he had fractures .that's harm . During an interview on 9/14/2023 at 11:38 AM, the Administrator confirmed fall interventions should be person centered. He stated it was his expectation for staff to report any falls so a nurse can assess the resident. Further interview revealed the Administrator confirmed Resident #74 should not have been left in the bathroom alone unattended (exact date of fall unknown 8/1/2023 or 8/2/2023). During an interview on 9/15/2023 at 2:35 PM, the DON stated, .[Resident #74] reported that he fell in the bathroom [on 8/1/2023 or 8/2/2023 date unknown] . The DON confirmed the new intervention added to the care plan after the fall reported on 8/2/2023 was a contour mattress to assist the resident from not falling out of bed. The DON confirmed the intervention put in place was not an appropriate intervention to prevent further falls. In summary, Resident #74 sustained a shattered Left Acetabulum (the socket of the hipbone) and Simple Fracture of the Left Pubic Ramus (Pelvic fracture) after a fall on 8/2/2023. The facility failed to thoroughly investigate, and implement appropriate fall interventions to future prevent falls. The facility's failure placed Resident (#74) in Immediate Jeopardy. Resident #253 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Non-Stemi Myocardial Infarction, Dysphagia, Anxiety Disorder, and Difficulty Walking. Review of Resident #253's baseline care plan dated 3/30/2023, showed .History of falls .Orient to room/call light .most used items within reach .Bed low position .Visual checks every 2 hours and as needed x 72 hours . Review of Resident #253's comprehensive care plan dated 4/17/2023, showed .Self-Care Deficit related to .assist X [times] (2) team member/members for bed mobility and repositioning .The resident is at risk for falls r/t Gait/balance, Incontinence, Hemiplegia .Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response for assistance . Review of Resident #253's quarterly MDS dated [DATE], showed the resident had a BIMS score of 15, indicating she was cognitively intact. The resident required extensive assistance of 2 staff members for bed mobility and toilet use, she was dependent on 2 staff members for transfers, she required extensive assistance of 1 staff member for locomotion on unit, personal hygiene, and dressing. The resident did not have any falls during the 7-day lookback period. Review of Resident #235's nurse's progress note dated 6/11/2023, showed .Alert with confusion noted . Review of Resident #253's nurse's progress note dated 6/12/2023, showed .Alert with confusion noted . Review of Resident #253's facility's fall investigation dated 7/10/2023, showed .This nurse heard resident yell out for help. Went into residents room where she was lying in the floor beside the bed on her left arm .Resident unable to give description .Left side of head was bleeding and she was complaining of shoulder and back pain. Vitals taken WNL [within normal limits]. Contacted [Ambulance] to take to ER .Injury Type .Laceration .face . Review of Resident #253's comprehensive care plan update on 7/10/2023, revealed .Fall 7/10/2023. Sent to ER for evaluation .will update with new interventions on return from hospital . Review of Resident #253's Emergency Department note dated 7/10/2023, showed .presenting after a fall from her bed at her facility .Patient sustained left hip fracture .Orthopedics has been consulted for left hip .Dx [diagnosis] Fall .Forehead laceration .Left hip fracture .Laceration repair .Laceration length .3 cm [centimeters] .Number of Sutures .3 . Review of Resident #253's hospital Discharge Summary dated 7/24/2023, showed .Discharge Diagnosis .Fall from bed .Forehead laceration. Repaired in ER .Left femoral IT [Intertrochanteric] fracture. S/P [status post] .repair .Advanced Dementia .discharge home with home health . During an interview on 8/22/2023 at 1:25 PM, LPN #7 stated, .right before she got sent out I would hear her hollering and I would go down there and she would be sideways in the bed .when she came here she had fallen at home .we all knew she could fall . The LPN confirmed she was not aware of any intervention the facility had in place to address the resident trying to get out of bed without assist and being found sideways in the bed. During an interview on 8/24/2023 at 12:11 PM, LPN #5 stated .she was one of our hospice patients .she was very confused .one minute she would be with it and the next minute she was talking about rainbows and [NAME] land .we were constantly having to get her up [out of bed to a chair] because she would be putting her feet over the side of the bed trying to get up .had several days I would come in [to work] and they [night shift] would say [Resident #253] was trying to climb out of bed all night .LPN #5 stated the interventions used to prevent falls for Resident #253 were .keeping her bed in lowest position, keeping her call light in reach, we would go in more frequently .more frequent checks, if she was trying to get up we would go ahead and get her up and bring her to the day room . During a telephone interview on 8/29/2023 at 8:15 PM, CNA #7 confirmed Resident #253 would sometimes try to get out of bed without assistance .She stated on the night of 7/10/2023 .She heard somebody scream and me and [LPN #10] and the other nurse entered the room and the resident was sitting on the floor towards the door . CNA #7 stated, .call light within reach . She confirmed the resident was at risk for falls. Resident #253 had the diagnosis of Dementia and had periods of confusion. During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated Resident #253 .had a dx of dementia .I guess you would say that's harm if you fall and have a fracture . During an interview with the Administrator 9/14/2023 at 11:38 AM, the He confirmed Resident #253 did not have individualized interventions developed to prevent falls when she fell on [DATE] and sustained a left femur fracture. In summary, Resident #253 sustained a Left Femoral Fracture (break in the thigh bone) after a fall on 7/10/2023. The facility failed to to implement appropriate fall interventions to prevent future falls after the resident was known to be confused and attempted to get out of bed without assistance. The facility's failure placed Resident #253 in Immediate Jeopardy. Resident #149 was admitted to the facility on [DATE], with diagnoses including Unspecified fracture of Right Femur, Unspecified Dementia, Adult Failure to Thrive, Alzheimer's Disease, Unspecified Hearing Loss, Insomnia, Unsteadiness on Feet, and Depression. She was discharged on [DATE]. Review of Resident #149's comprehensive care plan dated 5/2/2023, showed . physical deficit with transfers .Hoyer Total Lift Large (Green) Sling .Transfer/Slide Sheet for moving up in bed .Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, femur fracture, pain, weakness .Extensive assist x [times] 2 team member/members for bed mobility and repositioning . Further review showed no documentation a care plan had been developed to address Resident #149's risk for falls. Review of Resident #149's admission MDS dated [DATE], showed the resident had a BIMS of 99 which indicated the resident was rarely or never understood. She required extensive assistance of 2 staff members for bed mobility, transfers, dressing, and toileting. She had falls in the past month and the past 2-6 months prior to admission. Review of Resident #149's Post Fall Review dated 5/9/2023, showed, .fall .05/09/2023 .18:30 [6:30 PM] .Activity at time of fall .other .sitting in wheelchair to her peddles [pedals] .in her room by bathroom door .she was trying to stand up and take herself to the bathroom History of falls .no apparent injury .not witnessed .Immediate actions .Assisted resident off of her wheelchair peddles [pedals] and back in to her wheelchair. Educated Resident to use call light [Resident #149's cognition was impaired] . Review of the facility's investigation dated 5/9/2023, showed Resident #149 had a fall on 5/9/2023 .Resident was found on wheelchair pedals no injury noted .Resident stated she was going to the bathroom .the resident was assessed for injury .None noted and was assisted back to her wheelchair . Record review of Resident # 149's comprehensive care plan showed .Actual fall on 5/9/2023 .Be sure the resident's call light is within reach and encourage resident to use it for assistance .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c [wheelchair] . No other interventions had been developed to address Resident #149's risk for falls. Review of Resident #149's nurses progress note dated 5/17/2023, showed .CNA told this nurse that [Resident #149] .had a fall. After assessing [Resident #149] it was found that she had a laceration to the back of her head, she was bleeding a lot, a cold cloth was held to the back of her head with pressure to help stop the bleeding .orders received to send [Resident #149] to .ER [emergency room ] . Review of Resident #149's Post Fall Review dated 5/17/2023, showed there were no immediate actions documented. Review of Resident #149's emergency room Documentation dated 5/17/2023, showed .unwitnessed fall with bleeding from back of head .Impression .Acute extra-axial hemorrhage right temporal region .concerning for epidural hematoma . Review of Resident #149's Palliative Care Consult Note from the hospital dated 5/18/2023, showed .96-yo female with Alzheimer's dementia and cerebrovascular disease, also right femur fracture in April 2023 [related to a fall at home] treated conservatively without surgery. She was transferred 5/18/23 after fall from standing with epidural hematoma. Per neurosurgical evaluation family declined operative intervention . Review of facility documents revealed the resident' falls, for Resident #149, #253, and #74 were not completely investigated so root cause analysis and contributing factors were not identified. During an interview on 8/23/2023 at 3:07 PM, LPN #12 stated .the nurse confirmed Resident #149 did have a fall on 5/9/2023 .that was her first fall so she should have had just the basic general interventions making sure her positioning is good making sure she wasn't in pain or anything that would cause her to want to get up .I don't know her BIMS so I don't know if she was one that you could remind .gives cues and things . LPN #12 stated .when they are admitted we generally figure everyone's at risk for falls . During an interview on 8/24/2023 at 12:11 PM, LPN #5 stated she had completed the post fall evaluation after Resident #149's fall on 5/9/2023 .unit managers would add a new intervention to the care plan. LPN #5 confirmed she does not investigate the falls .I just put what I immediately done . LPN #5 stated she does not review the care plan prior to adding the immediate intervention and would not know if it had already been on the care plan. She stated .if it's someone that falls a lot then staff check in on them a lot . During an interview on 9/5/2023 at 3:13 PM, LPN #11 stated when a resident has a fall the new intervention would be added to the care plan by LPN #12 .we record the fall and make sure there's no injury, inform the doctor and family member .[LPN #12] implements new interventions . During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated it was her expectation for the facility to develop a fall risk care plan for residents who are at high risk. She stated encouraging Resident #149 to use her call light would not have been an effective intervention if she had severe cognitive impairment. The NP confirmed when Resident 149 fell on [DATE] and sustained an epidural hematoma that she had sustained harm from the fall .that is harm . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated .I attend the IDT meetings where we review falls and discuss interventions . He stated if a resident is at risk for falls it was his expectation for the facility to .develop a care plan intervention and implement it .so we should take account of any hospital records and family or acquaintance interviews as well as our own fall assessment .yeah I do [expect person centered interventions to be developed] . The Administrator confirmed the intervention to encourage use of the call light for Resident #149 was not appropriate (due to cognition) and confirmed if the facility had completed a thorough investigation of the fall on 5/9/2023 and implemented appropriate interventions the fall on 5/17/2023 could have been prevented. He confirmed the resident had sustained harm when she fell on [DATE] and sustained an Epidural Hematoma. In summary, Resident #149 sustained a Right Epidural Hematoma (when blood accumulates between the skull and the covering of the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) during a fall on 5/17/2023. The faci [TRUNCATED]

Based on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns with falls (Residents #149, #253, and #74) and elopement (Resident #252). The facility failed develop an effective QAPI program that recognized concerns related to safe smoking by Resident's (#202, #61, #16, and #48) and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement, falls and an unsafe smoking environment. The failure of the QAPI Committee to ensure a safe environment for smoking and to develop corrective actions for elopement and falls, placed all residents in Immediate Jeopardy (IJ). The Administrator was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F865. The facility was cited at F865 at a scope and severity of J. The Immediate Jeopardy began on 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy QAPI [Quality Assurance & Performance Improvement] Center Plan dated 7/7/2023, revealed, .Identify opportunities for improvement .Address gaps in systems or processes .Develop and implement an improvement or corrective plan .And continuously monitor the effectiveness of our interventions .Adverse event monitoring .causes are analyzed, and performance improvement activities are implemented . Review of the medical records for 3 residents (Resident #149, Resident #253, and Resident #74) revealed Resident #149 did not have a falls care plan developed after her first fall and sustained a second fall with major injury in 2023. Resident #253 had increasing confusion and restlessness, that was not addressed in her care planning, and had a fall with major injury in 2023. Resident #74 sustained a fall in his bathroom at a timeframe still undetermined, he stated his return to bed was done by 2 unidentified staff members and a mechanical lift, he was not assessed by the staff for an undetermined amount of time, perhaps greater than 12-16 hours, due to the night nurse stating the fall did not happen on her shift and it was discovered by the therapy staff at 10:00 AM the following day. Resident #74 was sent to the hospital with major injuries diagnosed . Review of facility documents revealed the 3 falls for Residents #149, #253, and #74 were not completely investigated so root cause analysis and contributing factors were not identified. Interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed, falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . Continued interview confirmed the QAPI committee did not revisit the effectiveness of the facility's plan of correction for falls and elopement submitted to the State Survey Agency in September of 2022. Review of Resident #252's medical record revealed he was exit seeking and wore a wander guard bracelet. Review of facility documents revealed Resident #252 eloped 3/4/2023, out of the front door of the facility, was on the grounds in his wheelchair for an undetermined amount of time before a staff member, leaving for the day, saw him in the parking lot, headed toward the street. Interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed he had expended a large sum of money to arm the front door to respond to the wander guard system. Interview confirmed an investigation was not completed to identify a root cause analysis and also examine the contributing factor of staff not recognizing the resident was out of the building for an undetermined amount of time. Continued interview confirmed the QAPI committee did not revisit the effectiveness of the facility's plan of correction for elopement that was submitted to the State Survey Agency in September of 2022 after an elopement. Review of the facility's yearly Center Assessment Tool, dated 7/20/2023, revealed the facility being a smoking facility was not addressed within the Physical Environment portion of the assessment, or within any part of the tool. Review of the medical records of 4 residents (Resident #202, Resident #16, Resident #61 and Resident #48) revealed unsafe practices with smoking. Review of Resident #16's care plan revealed a lack of threatening behaviors being addressed by the facility to ensure the safety of all the residents in the facility. Resident #202, #61 and #16 smoked in the designated smoking area and at designated smoking times. After the facility became aware of unsafe smoking practices the facility failed to protect the residents from potential harm related to smoking. During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, #16, and #48 were observed smoking unsupervised no changes were put in place to address concerns related to residents smoking unsupervised in the building. During observations of the 5 smoking breaks during various times of the survey revealed supervising staff failed to follow safety procedures, such as each smoker being assessed for smoking prior to participating, residents not wearing a smoking apron if required, a fire blanket was not present, ash trays were not emptied after the last smoke break, and appropriate ash trays/cans were not in use to prevent potential fires. During an interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed the QAPI committee had not addressed the ongoing problem with smokers occasionally smoking unsupervised (Resident #202, Resident #61, Resident #16, and Resident #48) facility policy for safe practices for supervised smoking not followed, and the threatening behaviors of Resident #16. Refer to F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Interview and review of the facility documentation revealed all members of the Quality Assurance Performance Improvement Committee were educated on the facility's Quality Assurance Policy and procedure and the important of conducting an ADHoc meeting when new concerns are identified to discuss and determine immediate actions needed to address the identified area of concern to prevent safety issues related to unsafe smoking, practices, falls, and elopement. The Committee was educated to continue meeting monthly and review the effectiveness of the plans and adjust the plans as needed to ensure and maintain compliance. Review and interview with the Administrator revealed he was educated by the Regional [NAME] President on 9/19/2023. Interviews with the Senior Director of Clinical Services, Director of Clinical Services, Discharge Care Coordinator (DCC), and Social Service Director confirmed they were educated. 2. Review of the facility documentation dated and interviews with all disciplines revealed the staff were educated to immediately report any identified deficient practice to the Administrator or DON to ensure the new concern can be addressed through the facility's Quality Assurance Performance Committee (QAPI). The QAPI Committee will initiate a plan of correction (POC) to include education any systemic changes, and auditing to ensure compliance was sustained. 3. Interviews with all disciplines revealed they were in-service to report any identified deficient practice to the Administrator or the DON to ensure the new concerns could be address by the QAPI Committee. Noncompliance at F-865 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, review of facility documents, observation and interviews, the governing body failed to establish and implement policies regarding effective management and training of the facility's new hires in key staff positions and operation of the facility. The Governing Body's failure placed 2 resident (#250 and #249) of 6 discharged residents reviewed for the potential of unsafe and non-orderly discharge; placed 3 residents (#149, #253, and #74) of 5 residents reviewed for falls at high risk for repeat falls; and the Administrator's failure to provide adequate leadership to address the elopement of 1 resident (#252) placed the resident in an unsafe environment. The governing body's failure to ensure staff were adequately trained resulted in unsafe discharges, falls with major injury, elopement and unsafe smoking practices for Resident's (#202, #61, #16, and #48) which placed all 99 residents in Immediate Jeopardy (IJ) (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 Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-837. The facility was cited at F-837 at a scope and severity of J. The Immediate Jeopardy began on 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the Social Services Director's job description included, .One year of supervised social work experience, in a healthcare setting, working directly with individuals .help solve health and welfare problems .makes appointments and acts as a liaison .develops discharge plans .Arranges for post discharge services and follow-up care . Resident #250 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Chronic Kidney Disease, Morbid Obesity, Weakness, and Unsteadiness on Feet. She was discharged to her home on 7/5/2023. Review of Resident #250's Occupational Therapy (OT) Discharge Summary dated 7/4/2023, showed .Patient will be discharging to facility (seeking additional approval to stay here) as she is not ready to discharge home (needing max [maximum] assist with LB [lower body] ADLs [activities of daily living) and significant assist with transfers .1-2 [staff members]). Patient is making significant gains and would benefit from more skilled therapy services prior to when she eventually returns home .is not safe to discharge home at this time even with appropriate DME [durable medical equipment] available . Review of Resident #250's Home Health Visit Note Report dated 7/9/2023, showed .Integumentary .Abnormal integumentary assessment findings .Erythema .location .Groin, Buttocks .indicate Patient pain scale rating .8 .Patient with recent SNF stay .Her BLE [Bilateral Lower Extremities] is pitting 3 plus edema and has severe pain with movement. She is MAX assist .stand with 2 people .Patient was sitting in wheelchair alert and oriented x4 .She states she had been sitting in her own urine and feces since after being discharged from [name of nursing facility] .She was upset because she wasn't able to get up and clean herself up. Patient does not have assistance from anyone. Patient is needing more than home care services can provide. Nursing and Physical therapy could barely get patient to stand up to get stool off the patient. Patient's skin was excoriated from sitting in urine and feces for several days .She has severe pain when moving legs. Has wounds on both legs that are weeping. Patient agreed to go back to emergency room . Record review of Resident #250's hospital records, dated 7/12/2023, showed .patient . return home for approximately 3-4 days with failure to thrive .Patient home approximately 3-4 days with inability to care for self Assessment/Plan .Stage I decubitus ulcer and pressure area .Bilateral lower extremity edema .brought to ED [Emergency Department] .after being at home alone and not able to get up defecating on self .Patient lives alone .Patient unable to stand and ambulate and states home health cleaned her up .Over the past 3 days she has been unable to get up and defecating and urinating on herself .Patient states her bottom was hurting because of sores on at that she was defecating and urinating on herself .Skin .rash bilateral [both] anterior [front] shins .stage I [redness] sacral decubitus [bedsore above the tailbone area] ulcer bilateral as well as scattered multiple small 1 cm [centimeter] areas of stage II ulcer [shallow open bedsore] bilateral buttocks .ED course .brought to the emergency department disheveled, covered in feces and urine. Lives alone. Has not been able to get up or move and has been defecating on self for the past several days. Was discharged home after meeting her maximum rehab stay. Appears to have UTI [Urinary tract Infection]. Treated with IV [Intravenous] Rocephin [antibiotic] .Received IV fluids. Patient unable to stand or walk. She is severely and physically deconditioned. Patient is unsafe discharge home to continue solitary living even with intermittent home health . Review of Resident #250's After Care call [follow up from nursing facility] dated 7/13/2023, showed it was not completed. During an interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the facility's governing body included himself, the Director of Nursing, and the Regional [NAME] President of Nursing. The Administrator confirmed the processes in place for discharge were approved by the governing body. Interview continued and he confirmed he had not been aware PT and OT (physical and occupational therapy) had documented Resident #250 was not safe to be discharged home and stated he had not been aware the resident required the assistance of 2 persons for transfers. He confirmed the discharge had been unsafe for Resident #250 and stated the facility should have .ensured appropriate resources were in place prior to discharge . Resident #249 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's Psych NP note dated 6/6/2023, showed .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple complicities . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging, and we explained that would be AMA [against medical advice] and he didn't care, and he started packing his stuff . The Administrator stated the resident said he had a friend that was willing to take him in but he [Resident #249] did not know the friends name and stated it wasn't anyone listed in the resident's chart .he was gonna walk so I asked him not to do that .I was unable to get a taxi over here so I took him he told me where to go he did not know the address but he knew the streets .I watched him go to the door and his friend took him inside .it was a female . Interview continued, .we gave him the notice [involuntary discharge notice] but it had not run out [of days] yet .our Ombudsman informed me that was not an appropriate discharge destination so I rescinded that notice . The Administrator stated the resident had not had home to discharge to. I don't know if he had a plan [discharge plan] .I had to give him a discharge notice and up until that point he had not given me any other address .typically we want to get things in order and notify the physician and he said I'm leaving and went to pack his stuff up . During an additional interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the resident did not have a home .to my knowledge he [Resident #249] didn't have a home .he [Resident #250] discharged AMA and I helped provide him [Resident #249] transportation to a home . He [Resident #250] confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed Resident #249 had not been discharged to a safe environment. The facility's failure to provide a safe discharge for a previously homeless resident (#249) resulted in homelessness on the day of discharge. The nursing home administrator took Resident #249 to an unidentified friend's home. The friend did not allow Resident #249 to stay. Resident #249 walked from the friend's home to a second friend's house who drove him to a motel where he stayed for 2 months, was evicted, then hitchhiked to a third friend's home. The facility's non-compliance in providing a safe and orderly discharge for each resident discharged requires immediate action to prevent re-occurrence. Resident #149 was admitted to the facility on [DATE], with diagnoses including Unspecified fracture of Right Femur, Unspecified Dementia, Adult Failure to Thrive, Alzheimer's Disease, Unspecified Hearing Loss, Insomnia, Unsteadiness on Feet, and Depression. She was discharged on [DATE]. Review of Resident #149's nurses progress note dated 5/17/2023, showed .CNA told this nurse that [Resident #149] .had a fall. After assessing [Resident #149] it was found that she had a laceration to the back of her head, she was bleeding a lot, a cold cloth was held to the back of her head with pressure to help stop the bleeding .orders received to send [Resident #149] to .ER [emergency room ] . Review of Resident #149's Post Fall Review dated 5/17/2023, showed there were no immediate actions documented. Review of Resident #149's emergency room Documentation dated 5/17/2023, showed .unwitnessed fall with bleeding from back of head .Impression .Acute extra-axial hemorrhage right temporal region .concerning for epidural hematoma . Review of Resident #149's Palliative Care Consult Note from the hospital dated 5/18/2023, showed .96-yo female with Alzheimer's dementia and cerebrovascular disease, also right femur fracture in April 2023 [related to a fall at home] treated conservatively without surgery. She was transferred 5/18/23 [5/18/2023] after fall from standing with epidural hematoma. Per neurosurgical evaluation family declined operative intervention . During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated it was her expectation for the facility to develop a fall risk care plan for residents who are at high risk. She stated encouraging Resident #149 to use her call light would not have been an effective intervention if she had severe cognitive impairment. The NP confirmed when Resident #149 fell on [DATE] and sustained an epidural hematoma that she had sustained harm from the fall .that is harm . Review of the medical record for Resident #149 revealed the resident did not have a falls care plan developed after her first fall and sustained a second fall with major injury. Resident #149 sustained a Right Epidural Hematoma (when blood accumulates between the skull and the covering of the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) during a fall on 5/17/2023. Resident #253 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Non-Stemi Myocardial Infarction, Dysphagia, Anxiety Disorder, and Difficulty Walking. Review of the medical records Resident #253 had increasing confusion and restlessness not addressed in her care planning and had a fall with major injury. Resident #253 sustained a Left Femoral Fracture (break in the thigh bone) after a fall on 7/10/2023. Review of Resident #253's facility's fall investigation dated 7/10/2023, showed .This nurse heard resident yell out for help. Went into residents room where she was lying in the floor beside the bed on her left arm .Resident unable to give description .Left side of head was bleeding and she was complaining of shoulder and back pain. Vitals taken WNL [within normal limits]. Contacted [Ambulance] to take to ER .Injury Type .Laceration .face . Review of Resident #253's comprehensive care plan update on 7/10/2023, revealed .Fall 7/10/2023. Sent to ER for evaluation .will update with new interventions on return from hospital . During an interview on 9/14/2023 at 3:50 PM, the Administrator stated .falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . The facility failed to provide adequate supervision to prevent further falls for Residents #149, and #253. Thorough investigations were not completed to include a root cause analysis to facilitate individualized fall prevention interventions for Residents #149. The facility failed to implement appropriate interventions to prevent falls for Residents #149, and #253. Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/15/2023 with diagnoses including Fracture of the Left Acetabulum, Chronic Obstructive Pulmonary Disease, Diabetes and Congestive Heart Failure. Review of Resident #74's Nurse Practitioner's note, dated 8/2/2023, showed .Called to room. Pt. c/o [complaint of] hip pain. He reports he fell in the bathroom- he is found in bed .Nursing and PT staff are present. He has c/o [complaint] severe pain to lt. [Left] hip with attempts to move him. He has knot to lt. [Left] outer hip .acute Left hip pain self-report of unwitnessed fall in bathroom . Review of Resident #74's EMS [emergency medical service] records, dated 8/2/2023, showed .pt was found lying semi [NAME] s [head of bed raised to 30-degree angle] in bed, alone. The crew asked the pt [patient] what happened .he said he fell sometime yesterday when it was day light and started having left hip pain this morning .The nurse stated he fell sometime in the night and is complaining of left hip pain . Review of Resident #74's hospital record, dated 8/2/2023, showed .c/o fall and hitting head but unsure when he fell . Per NH [Nursing Home] pt fell last pm but pt states it was in the daylight yesterday .Pt does c/o headache and is on blood thinners .He reportedly is on blood thinners and hit his head. Unknown loss of consciousness as he is somewhat confused to the event .New area of suspected bruising along the left hip has more hyperdense appearance than other areas of edema .The left acetabulum is fractured , multiple fracture planes, some intersecting the acetabular margin .No evidence of left femoral fracture or dislocation .Impression: The left acetabulum has been shattered .Simple fracture to the inferior left pubic ramus .Small superficial hematoma along the left outer hip . The Governing Body failed to develop evidence based best practice policies to address falls and fall prevention. The ongoing problem of falls, identified as the primary unsafe adverse outcome by the Administrator, not being addressed by the QAA committee in 2023. The governing body had not provided oversight and accountability of the QAA committee to develop effective corrective actions to address elopement and unsafe smoking. Record review showed Resident #252 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Alcohol Abuse, Acute Kidney Failure, and Cognitive Communication Deficit. Review of Resident #252's nurse's progress note dated 2/23/2023, showed .Resident states that he needs help. I asked what he needed, and he stated (I have to get out of this place) .He insists that he needs to go. Wander guard [bracelet to prevent exiting doors equipped with a wander guard sensor] placed on ankle . Review of Resident #252's nurse's progress note dated 3/4/2023 at 6:53 PM, showed .Patient exit seeking and redirected by therapy .Wanderguard in place and functional and patient placed on 15 min safety checks .Currently patient is positioned at the west nurse's station for extra precaution . Review of Resident #252's medical record showed no documentation the resident had eloped from the building, was found in the parking lot, and had been out of the building for an undetermined amount of time. Review of a text message provided by RN #4, undated, showed the Administrator had sent the RN a text message which showed .[Name of Administrator] .It needs to be something to the effect that he exhibited exit-seeking behavior and was redirected by staff. Wander guard in place. We don't need to say he was found outside .18:44 [6:44 PM] . During a telephone interview on 8/28/2023 at 2:25 PM, RN #4 (worked dayshift on 3/4/2023 on a different hall) stated .I knew a little after the fact .I heard he was out by the [facility sign by the road] sign .he was in his wheelchair . She stated she had not been assigned to care for the resident that day but had received a text message from the Administrator directing her on what she was to chart in the resident's medical record .so I was the only administration at the time [working that day] .I was directed on how to chart the incident [by the Administrator] .I have text messages by my Administrator .I do have the text message as to what to chart exactly .I know he did have a wanderguard on and he did get out the front door .RN #4 stated none of the staff realized the resident was missing .or how long he had been outside .he was a wanderer . She confirmed the Administrator directed her to chart [in the electronic medical record] vaguely. The RN confirmed the resident had been out of the facility for an undetermined amount of time on 3/4/2023. The RN confirmed the resident had a wanderguard bracelet in place, no alarm sounded on the front door to alert staff he had exited. The RN stated if the Physical Therapy Assistant (#1) had not seen the resident, .it would have been a while [before staff noticed he was missing] . The RN stated she did not feel the resident could have moved out of the way of a moving car in the parking lot .I don't think he would have realized it was dangerous and I don't think he could have gotten out of the way .oh yeah [could have been hit by a car] he wasn't communicating at that time from the stroke .no [could not have controlled the wheelchair on the slant of the parking lot toward the road] .he could have tipped the wheelchair over .I don't think he could have stopped it [the wheelchair], he could use his left hand a little .if he had tipped over [the wheelchair] he could not have gotten himself up on his own . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated he was unable to remember how he had been made aware of Resident #252's elopement on 3/4/2023 .I do not recall . He confirmed the incident had not been documented in the resident medical record. He confirmed the incident should have been documented and stated he was not aware of why the incident had not been .in hindsight there [are] opportunities for me to improve . During an interview on 9/13/2023 at 3:10 PM, with the Administrator he confirmed the Social Services Director (SSD) inability to provide a safe discharge for Resident #250. He responded .opportunity to improve .plan to reach out to 1 of our other centers to come here to train her [SSD] . Continued interview confirmed the Discharge Car Coordinator (DCC) had 1 day of training with a traveling DCC. During an interview on 9/14/2023 at 3:50 PM, the Administrator stated falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed . Resident #202 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Patient's Noncompliance with other Medical Treatment and Regimen, Acute and Chronic Respiratory Failure with Hypoxia, and Schizoaffective Disorder Bipolar Type. The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #202 smoked in the designated smoking area. The facility failed to investigate the unsafe smoking incident for Resident #202. Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder Bipolar Type, Anxiety, and Acute Chronic Diastolic Heart Failure. The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #61 smoked in the designated smoking area. The facility failed to investigate Resident #61's unsafe smoking practices. Resident #16 was admitted to the facility on [DATE], with diagnoses including Acute on Chronic Diastolic Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Peripheral Vascular Disease, Major Depression Disorder, and Chronic Kidney Disease. Review of Resident #16's Activities note dated 11/28/2022, revealed .This AD saw this resident out in the courtyard with two other residents [Resident #61 and Resident #16] smoking a cigarette unsupervised and not at designated smoking times .I went outside explained to this resident that is was not time to smoke [that it was not the time to smoke] and told him to put thecigarette [the cigarette] out .He then told me to leave him the [expletive] alone and go back inside .I told him I would when the [Resident #16] put the cigarette out he then threw it in the flower pot still lit .I put the cigarette out while he was telling me to leave it alone .I then went inside and reported it to the nurse on [name of the hall] and the ADON . Review of Resident #16's Activities note dated 4/19/2023, revealed .[Name of Resident #16] .was seen by multiple other residents put a cigarette in his shirt pocket .He then went into the facility . [Name of medical records personnel] was smoking the [monitoring residents smoking in the designated smoking area]residents at this time and informed me of him having the cigarette .I stoppedhim [stopped him] in the front hall I could visibly see the cigarette .I said to him that he could not have the cigarette .that he needed to give it to me .He said it was broken and he was going tofix [to fix] it .He said I don't have a lighter I have a broken cigarette .He continued to argue about not giving to me but did eventually hand me the cigarette .The cigarette was not broken I took the cigarette out to the box realizing that it wasn't one of [Resident #16's] own cigarettes .The other smokers said that another female smoker gave him the cigarette . The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #16 smoked in the designated smoking area. The facility failed to investigate Resident #16's unsafe smoking incidents. During an interview on 9/14/2023 at 8:22 AM, the Administrator stated, .We treat the incidents of smoking unsupervised or violation of smoking [as a resident smoking incident] .resident holding on to cigarette not disposed in trashcan [when residents attempt to keep their cigarettes on themselves or in their rooms] .We write in the progress notes instead . Problems related to smoking typically discussed with the interdisciplinary team [IDT] team .He [Resident #16] was discussed in 9/2023 he[Resident #16] had cigarette in his possession . During an interview on 9/14/2023 at 9:02 AM, LPN #12 stated, .There are occasions when residents [are] caught smoking unsupervised on both shifts .Some families give residents the cigarettes or visitors will come in and residents ask them for cigarettes and visitors give [residents cigarettes] .If family brings cigarettes [in to residents] they bring them lighters .If visitor come [in to visit residents] they light cigarettes for residents .[For Residents# 202, #61, and #16] it was [Resident #202's Family member brought the cigarettes in at that time [11/28/2022] .She [Resident #202's Family member brought packs [cigarette packs] in and gave the resident [Resident #202] the cigarettes. [Resident #202] told me her Family member brought her in the cigarettes over weekend of 11/28/2022. When I saw her [Resident 202's Family Member] that day[unknown date] .[LPN #12] told her [Resident #202's Family Member] .she definitely could not give her [Resident #202] a lighter for any reason .She {Family Member] told me she was sorry and didn't realize it was a big deal to give cigarettes .to residents or light cigarettes for them .I told the resident [Resident #202] she had to turn those [cigarettes] in .I don't know how many cigarettes she gave me .not sure how many she had .I would guess central supply took them in [central supply staff] .[Resident #202 Family Member] admitted that she had been giving the resident [Resident #202]cigarettes' and maybe lighter [LPN #12 was unsure if Resident #202's Family Member provided Resident #202 with a lighter] if another visitor or someone else family lit the cigarettes .I was made aware by resident [Resident #202] because they [Resident #202, #61 and #16] had got caught [smoking in the designated smoking area unsupervised] on 11/28/2022 . Resident #48 was admitted to the facility on [DATE], with diagnoses including Nicotine Dependence, Chronic Respiratory Failure with Hypoxia, Unspecified Mood [affective] Disorder, Morbid Obesity, Obstructive Sleep Apnea, and Type 2 Diabetes Mellitus. Review of a nurses note dated 9/10/2023 at 10:17 AM, by Licensed Practical Nurse (LPN) #11 showed .Resident noted with a cigarette butt and ashes on the floor by his bed. Also noted with a pack of cigarette on his bedside table. Resident stated that cigarette just fell out of his pocket. Educated resident on not smoking in his room or inside the facility due to safety hazard. Resident is on continuous O2 [oxygen] therapy. Incident reported to supervisor for f/u [follow up] . During an interview on 9/14/2023 at 10:20 AM, CNA #1 confirmed she had observed Resident #48 smoking unattended within the past 2 weeks, CNA stated she reported the observation to the nurse (LPN #11). During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . The facility failed to provide adequate supervision, safety measures such as fire blanket and smoking apron. The facility failed to investigate the incident of Resident #48 when he was smoking unsupervised. During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, and #16 were observed smoking unsupervised no changes were put in place to address concerns related to residents smoking unsupervised in the building. During an interview on 9/18/2023 at 9:07 AM, with the Administrator, he would not engage in conversation related to the unsafe practices observed with smoking. The Administrator did confirm, after the incident on 11/28/2022, when 3 residents were found smoking unsupervised, no changes were put in place by the facility to address safe smoking, and it continued to be a concern. The Governing Body was not made aware by the Administrator of the unsafe smoking practices at the facility, the topic was not discussed in QAPI or identified as a concern until the SA [State Agency] made the concern known during the survey. During an interview on 9/18/2023 at 9:07 AM, with the Administrator, he would not engage in conversation related to the unsafe practices observed with smoking. The Administrator did confirm, after the incident on 11/28/2022, when 3 residents were found smoking unsupervised, no changes were put in place by the facility to address safe smoking, and it continued to be a concern. The Governing Body was not made aware by the Administrator of the unsafe smoking practices at the facility, the topic was not discussed in QAPI or identified as a concern until the SA [State Agency] made the concern known during the survey. During an interview on 9/21/2023 at 4:15 PM, with the Senior Director of Operations, she stated the facility had not been following the policies and procedures, put into place with accompanying guides, to implement and/or revise care plans, facilitate safe discharges, develop individualized interventions in an effort to prevent falls, and decrease the risk of elopement. She stated if the policy and procedures were followed, communication within the IDT would be mandatory. The governing body should acknowledge responsibility for governance through effective leadership, focusing on indicators of outcomes of care that had placed all 99 residents in unsafe care environments. During an interview on 9/21/2023 at 4:15 PM, with the Senior Director of Operations, she stated the facility had not been following the policies and procedures, put into place with accompanying guides, to implement and/or revise care plans, facilitate safe discharges, develop individualized interventions in an effort to prevent falls, and decrease the risk of elopement. She stated if the policy and procedures were followed, communication within the IDT would be mandatory. The governing body should acknowledge responsibility for governance through effective leadership, focusing on indicators of outcomes of care that had placed all 99 residents in unsafe care environments. Refer to F656, F657, F660, and F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's documentation and interviews showed the HRC [human resource coordinator] upon completion of general orientation will complete education of 72-hour meeting and care coordination. 2. Review of facility documentation and interview revealed education was provided to the IDT Team regarding safe discharges, falls prevention, smoking safety, and elopement prevention. Interview of 4 Staff revealed education was completed. 3. Review of facility documentation and interview the Governing Body conducted education with key personnel on 9/21/2023 to evaluate the need for re-orientation and to identify areas of concern and develop a training plan. Interview with the Director of Clinical Education revealed the facility is developed and implemented a training program on 9/19/2023. 4. The Director of Social Services received education regarding on safe and orderly discharges. Interview with the Social Services Director revealed she had completed education provided by the facility and had encouraged the facility to give more education. 5. The QAPI Committee conducted root cause analysis and developed the allegation of compliance, the finding of the RCA was a gap of understanding of key personnel in education on 72 hour and Care Coordination Meetings, Safe Discharges, fall prevention, smoking safety, and elopement prevention. Noncompliance at F-837 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, review of facility documentation, observation and interview, the facility's Administration failed to follow facility policy and procedures to ensure safe discharges for Residents #249 and #250; failed to provide adequate supervision for falls prevention, investigating, and implementing resident-centered interventions for 3 Residents (#149, #253, and #74); failed to provide effective leadership to address the elopement of 1 resident (#252); placing the Residents [#249, #250, #149, #253 and #74] in Immediate Jeopardy (IJ) , (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). Also, the facility's Administration failed to follow facility policy and procedures to ensure a safe smoking environment for Residents #202, #61, #16, and #48) which placed the residents in Immediate Jeopardy (IJ), (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 Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F835. The facility was cited at F835 at a scope and severity of J. The Immediate Jeopardy was effective 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy Discharge Planning dated 5/1/2012, showed, .The Social worker or designee will be responsible for discussing discharge plans with each resident .Updates and changes in discharge plans can occur at any time .Social Services responsibilities for assisting resident for discharge to home may include .setting up follow-up appointments, setting up home health, and assist in acquiring health related equipment . Review of the facility policy Discharge Against Medical Advice dated 5/1/2012, showed, .To assure that the resident .understands their actions .Every attempt to resolve their concerns should be made and this should be used only as a last resort. Inform the resident .of the possible complications of their discharge action .Anytime someone discharges Against Medical Advice [AMA] and the facility believes this is an unsafe discharge, Adult Protective Services [APS] must be notified . Review of the facility policy Falls dated 2/2017, showed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .when a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed .the intervention is documented on the care plan and on the caregiver guide .The identified intervention is initiated .Post fall .The patient is physically assessed for injuries .A fall huddle is called to help in investigating circumstances around the fall .The post fall evaluation is completed to assist in developing interventions to prevent future falls .The fall event and intervention is recorded on .patient's care plan and caregiver guide .Implement intervention identified .IDT [Interdisciplinary Team] reviews post fall investigation and summaries the recommendations for interventions . Review of the facility policy Elopement dated 4/2017, showed, .When an elopement occurs .Document condition notifications and times of actions deployed . Review of the facility's policy, Safe Smoking, dated 11/1/2016, revealed .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents .To assess the ability to smoke safely and determine any measures needed to protect residents from possible self-inflicted injury due to smoking .Any resident who identifies themselves as desiring to smoke .will be assessed for safety related to smoking .This assessment will be reviewed and updated with any change of condition .The results of the safety evaluation will drive the care plan interventions related to safe smoking .A resident may be re-evaluated for safety needs if there is an observed change in their ability to smoke safely .Tobacco materials (cigarettes/cigars .) themselves, in addition to fire igniting materials, may have increased control or be removed if smoking policy violations have occurred or as general safety policy for all residents .For the benefit of our non-smoking residents, smoking residents may only smoke in the designated Smoking Area at the center .Supervised smokers can only smoke with a staff member present in the smoking area .Various types of protective equipment are to be available in each center .Protective equipment may include fire blankets at each designated smoking area and smoking aprons for individuals assessed as requiring this safety equipment .Each designated smoking area is provided with ashtrays made of noncombustible material and safe design . Resident #249 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's Psych NP note dated 6/6/2023, showed .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple complicities . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging, and we explained that would be AMA and he didn't care, and he started packing his stuff . The Administrator stated the resident said he had a friend that was willing to take him in but he [Resident #249] did not know the friends name and stated it wasn't anyone listed in the resident's chart .he was gonna walk so I asked him not to do that .I was unable to get a taxi over here so I took [transported] him he told me where to go he did not know the address but he knew the streets .I watched him go to the door and his friend took him inside .it was a female . Interview continued, The Administrator referenced the discharge notice and resention by stating .we gave him the notice [involuntary discharge notice] but it had not run out [of days] yet .our Ombudsman informed me that was not an appropriate discharge destination so I rescinded that notice . The Administrator stated the resident did not have home to discharge to and had contacted the Ombudsman about the resident discharging to a homeless shelter. The Ombudsman voiced strong objection of the resident discharging to a homeless shelter. The resident ultimately resided in a hotel for 2 months and was evicted for non-payment. I don't know if he had a plan [discharge plan] .I had to give him a discharge notice and up until that point he had not given me any other address .typically we want to get things in order and notify the physician and he said I'm leaving and went to pack his stuff up . During an additional interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the resident did not have a home .to my knowledge he [Resident #249] didn't have a home .he [Resident #250] discharged AMA and I helped provide him [Resident #249] transportation to a home . He [Resident #250] confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed Resident #3 had not been discharged to a safe environment. During interview on 9/13/2023 at 3:10 PM, with the Administrator concerning the unsafe discharge of Resident #250, the Administrator stated the discharge didn't sound optimal. He offered the Social Services Director (SSD) failed to fax to the home health provider, didn't follow up with the home health services or Resident #250. The Administrator agreed the SSD lacked serious competency to provide a safe and orderly discharge. The Administrator confirmed the SSD needed additional training. Interview revealed the Administrator didn't want to speculate in reference to Resident #250's unsafe discharge that led to her remaining in the wheelchair she was placed in for 4 days, in her own urine and feces and readmitted to the hospital 6 days after discharge with several Decubitus ulcers. Review of the medical records for 3 residents (#249, #253, and #74) revealed Resident #2 did not have a falls care plan developed after her first fall and sustained a second fall with major injury in 2023. Resident #253 had increasing confusion and restlessness not addressed in her care planning and had a fall with major injury in 2023. Resident #74 sustained a fall in his bathroom at a timeframe still undetermined. Resident #74 stated his return to bed was done by 2 unidentified staff members and a mechanical lift. Resident #74 was not assessed by the staff for an undetermined amount of time, perhaps greater than 12-16 hours, due to the night nurse stating the fall did not happen on her shift. It [the fall/injury] was discovered by the therapy staff at 10:00 AM the following day. Resident #74 was sent to the hospital with major injuries diagnosed . Review of facility documents revealed the 3 resident falls, for Residents #149, #253, and #74 were not completely investigated so root cause analysis and contributing factors were not identified. During an interview on 9/13/2023 at 3:35 PM, with the Administrator, the fall for Resident #74 was reviewed. The Administrator revealed he had not interviewed Resident #74 after his fall in the facility on 8/1/2023 or 8/2/2023. Interview revealed he had not made any inquiries about what had actually occurred causing Resident #74 to sustain major injuries with a shattered Acetabulum (hipbone) and fracture pelvic bone. Continued interview revealed the Administrator was not aware Resident #74 was put back to bed from the floor by 2 unidentified staff members, with the help of a mechanical lift. Interview revealed the Administrator was unaware the resident was not assessed from the time of the fall until the rehab staff discovered his injury due to pain on movement and a large amount of bruising at 10:00 AM on 8/2/2023. The Administrator confirmed Resident #74 was left in an extremely unstable condition from the time of the fall until he was admitted to the hospital after 11:30 AM the 8/2/2023. During an interview on 9/14/2023 at 3:50 PM, the Administrator stated, falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . Continued interview revealed the QAPI committee, led by the Administrator, did not revisit the effectiveness of the facility's plan of correction for falls and elopement submitted to the State Survey Agency in September of 2022. Record review showed Resident #252 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alcohol Abuse, Acute Kidney Failure, and Cognitive Communication Deficit. He was discharged on [DATE] to an Assisted Living Facility. Review of Resident #252's Elopement Risk Evaluation dated 2/23/2023, showed .Is the resident physically able to leave the building on their own .Yes .Is the resident cognitively impaired .Yes .Is there a history of wandering or elopement .Yes .Wanderguard in place . Review of Resident #252's nurse's progress note dated 3/4/2023 at 6:53 PM, showed .Patient exit seeking and redirected by therapy .Wander guard in place and functional and patient placed on 15 min safety checks at this time. Currently patient is positioned at the west nurse's station for extra precaution . Review of Resident #252's medical record showed no documentation the resident had eloped from the building, was found in the parking lot, and had been out of the building for an undetermined amount of time. Review of a picture of a text message provided by RN #4, undated, showed the Administrator had sent the RN a text message which showed .[Name of Administrator] .It needs to be something to the effect that he exhibited exit-seeking behavior and was redirected by staff. Wander guard in place. We don't need to say he was found outside .18:44 [6:44 PM] . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated he was unable to remember how he had been made aware of Resident #252's elopement on 3/4/2023 .I do not recall . He confirmed the incident had not been documented in the resident medical record. He confirmed the incident should have been documented and stated he was not aware of why the incident had not been .in hindsight there opportunities for me to improve . He confirmed a thorough investigation had not been completed. He stated he had not reported the incident to the State Survey Agency because .when you look at the state reporting website it tells me that it is not a reportable incident so I took it as we do not report incidents of elopement without serious injury .I didn't feel like it met that criteria so if I was wrong .if I had looked at it in a different fashion I would have reported it . The Administrator confirmed Resident #252 had been in the parking lot unattended for an undetermined amount of time and the resident was at risk for injury or harm .his potential for risk was increased yes . During the course of the investigation portion of the survey concerns were identified of Residents' #202, #61, and #16 had smoked in the designated smoking area at undesignated smoking times and were unsupervised during the smoking session. After the facility became aware of the unsafe smoking practices of the residents' no preventive measures were implemented. The facility failed to protect all residents from potential harm related to unsafe smoking practices. During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, and #16 were observed smoking unsupervised no changes were put in place to address concerns related to residents not smoking safely at the facility. Resident #48 was admitted to the facility on [DATE], with diagnoses including Nicotine Dependence, Chronic Respiratory Failure with Hypoxia, Unspecified Mood [affective] Disorder, Morbid Obesity, Obstructive Sleep Apnea, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated 8/15/2023, revealed .The resident [Resident #48] has a behavior problem r/t [related to] .attempts to smoke without supervision .Focus .At risk for smoking related injury related to being a smoker .Goal .Will have no smoking related injuries through next review .Interventions .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Review smoking policy with patient and or family as needed .Storage of smoking materials per Center policy .has the potential for impaired breathing due to dx [diagnosis] of acute on chronic respiratory failure, COPD [chronic obstructive pulmonary disease], CHF [congestive heart failure], Obstructive Sleep Apnea. Non-compliant with O2 [oxygen] and CPAP [continuous positive airway pressure - a device to aid in breathing when sleeping] use . Review of Resident #48's Smoking assessment dated [DATE], showed Resident #48 was currently a smoker and intended to smoke while residing at the facility. Resident had no history of smoking related incidents documented. Resident #48 was documented to be cognitively intact, able to make himself understood, able to remain alert during the course of smoking, and able to communicate the need for help if lit materials fall on him. Resident required wheelchair access to smoking area. The summary concluded resident would not require supervision with smoking. Staff reviewed the policy related to smoking times and storage of smoking materials with the resident. Interventions were implemented and care plan was updated. Review of the Resident #48's admission MDS dated [DATE], revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed the resident required extensive assist of 2 staff members for bed mobility, toileting, dressing and transfers. During an observation on 9/7/2023 at 10:18 AM, revealed Resident #48 seated upright in a wheelchair, in the smoking area with a lit cigarette. Gauze dressings intact to both lower extremities. Resident observed without a smoking apron in place while smoking. Resident #48 without an oxygen container in place on the wheelchair. Staff were present during the smoke break. Review of a nurses note dated 9/10/2023 at 10:17 AM, by Licensed Practical Nurse (LPN) #11 showed .Resident noted with a cigarette butt and ashes on the floor by his bed. Also noted with a pack of cigarette on his bedside table. Resident stated that cigarette just fell out of his pocket. Educated resident on not smoking in his room or inside the facility due to safety hazard. Resident is on continuous O2 [oxygen] therapy. Incident reported to supervisor for f/u [follow up] . Review of Resident #48's Smoking assessment dated [DATE], showed Resident #48 currently smoked at the facility, resident was able to verbalize/demonstrate an understanding of the facility's smoking policy, times to smoke and place to smoke. The summary concluded resident would require supervision with smoking, and resident would require the use of smoking apron while smoking. Staff reviewed the policy related to smoking times and storage of smoking materials with the resident; care plan initiated/updated. During an observation on 9/12/2023 at 10:17 AM, Resident #48 seated upright in a wheelchair, in the smoking area with a lit cigarette. Gauze dressings intact to both lower extremities. Resident observed without a smoking apron in place while smoking. Resident #48 without an oxygen container in place on the wheelchair. Staff were present during the smoke break. Review of a nurses note dated 9/12/2023 at 12:24 PM, Registered Nurse (RN) #2 wrote .Late entry .On Sunday 9/10/23 at approximately 10:30 AM .nurse informed me that [Resident #48's name] had cigarettes in his room. As this is a safety issue, I went into [Resident #48's name] room and removed all of the cigarettes that were on his bedside table and on the floor beside his bed. Patient denied that he was smoking in his room. I educated the resident on the facility smoking policy. I informed him that because he is utilizing oxygen in the room, he is at risk of hurting himself and others if he smokes in his room. I also asked him to turn over any cigarettes that visitors and family bring in for him into the nurses station. I let him know that these cigarettes would be available to him during designated smoke times. Patient voiced understanding . During an observation on 9/13/2023 at 1:23 PM, Resident #48 in the smoking area, sitting upright in a wheelchair with a lit cigarette in hand. Gauze dressings intact to both lower extremities. Resident without oxygen container on wheelchair. Resident #48 had no smoking apron in place while smoking. Staff were present during the smoke break. During an observation on 9/13/2023 at 4:10 PM, Resident #48 in the smoking area, sitting upright in a wheelchair with a lit cigarette in hand. The resident had gauze dressings intact to both lower extremities. The resident was without oxygen container on wheelchair. Resident #48 had no smoking apron in place while smoking. Staff were present during the smoke break and observed the resident not wearing a protective smoking apron. During an interview on 9/13/2023 at 4:11 PM, Cook #3 stated .I don't know his name .he's new and he is heavy and has bandages on his legs .I've had to wake him up with a cigarette in his hand . she confirmed the cigarette was lit when the resident was observed dozing off. During an interview on 9/13/2023 at 4:15 PM, the Director of Nursing (DON) stated .On Sunday [9/10/2023] a cigarette butt was found on [Resident #48's name] floor, under his bed . The DON confirmed when staff found the cigarette butt in the floor, under the bed, no incident report was completed or formal investigation documented, only a nurse's progress note was written in Resident #48's electronic medical record. The DON stated Resident #48 wears Oxygen while in his room. The DON confirmed Resident #48's smoking assessment was reevaluated on 9/11/2023. The DON confirmed Resident #48's diagnosis of Sleep Apnea was not taken into consideration when completing the new smoking assessment. During an interview on 9/13/2023 at 4:25 PM, Resident #48 denied going outside to smoke unattended. Continued interview revealed Resident #48 confirmed he had to be woken up at times during smoking sessions due to having Sleep Apnea. During an interview on 9/13/2023 at 4:44 PM, Dietary Aide #3 stated .I don't know them by names .I don't know their rules .I know I see a nurse out there with that box [smoking material box] .but sometimes they are by their selves . During an interview on 9/14/2023 at 9:50 AM, LPN #11 confirmed while observing the cigarette butt on the floor, she also had observed loose cigarettes and a pack of cigarettes. She suspected the resident's friends/family brought cigarettes in for Resident #48. LPN #11 confirmed resident needs to wear a smoking apron while on smoke breaks. During an interview on 9/14/2023 at 10:00 AM, CNA #8 stated Resident #48 goes out regularly for smoke breaks. CNA #8 stated the resident took extinguished cigarette butts and placed them in his shirt pocket and returned inside the building. CNA #8 stated the incident was not reported to nursing of Resident #48 bringing extinguished cigarette butts back in the building. During an interview on 9/14/2023 at 10:08 AM, RN #2 confirmed she was made aware on 9/10/2023, a cigarette butt was found on the floor under Resident # 48's bed. RN #2 stated loose cigarettes and a pack was in the room on the bedside table. RN #2 confirmed she gathered the cigarettes and placed them in the smoking box RN #2 confirmed no lighter was present in the room, she stated she asked the resident, and he denied having a lighter. RN #2 stated she spoke with Resident #48's emergency contact and reviewed the smoking policy as to how cigarettes may enter the facility. RN #2 confirmed the CNA's from either side (East and West) alternate the times for when they monitor the smoke breaks. RN #2 confirmed the admission nurse completes the initial smoking assessment and residents are assessed as needed thereafter. During an observation of the designated smoking area on 9/14/2023 at 10:17 AM, revealed 12 residents were supervised for smoking with a CNA. The residents were seated in chairs and others were seated in their mobility devices. During an interview on 9/14/2023 at 10:20 AM, CNA #1 confirmed she had observed Resident #48 smoking unattended within the past 2 weeks, CNA stated she reported the observation to the nurse (LPN #11). During an observation on 9/14/2023 at 10:36 AM, the fire blanket pink/red box mounted on the wall in the designated smoking area and there was no fire blanket readily available for staff/residents in case of a fire while residents smoked in the designated smoking area. The fire blankets were replaced after the noncompliance was identified by surveyor. Refer to F660 and F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's documentation and interviews showed the Administrator, Discharge Care Coordinator, MDS Nurse, Social Services Director, and Unit Managers (IDT Team) on 9/19/2023 held a Care Coordination meeting to discuss safe discharges and the potential need for community services which would ensure a safe and orderly discharge and resident had accommodations to meet their needs. 2. Review of the facility's inservices and sign in sheets and documentation showed the Director of Care Coordination completed education regarding After Care Calls to be made on 2-3, 7-9, and 27-28 days post discharge. 3. Review of facility documentation and interview the Director of Clinical Education was provided education for falls prevention, investigation, and implementing resident centered interventions after each fall. Medical record review of 1 resident fall showed person centered interventions were implemented and verified in place. 4. Interview with the Administrator, Senior Director of Operations and Director of Operations revealed care coordination meetings were held to discuss residents who are scheduled to discharge, unplanned discharges will be discussed to ensure a safe, orderly discharge. 5. Review of facility documentation and facility's inservices and sign in sheets, and interview revealed Licensed Nursing staff received education regarding falls prevention, investigation, and implementing resident centered interventions. Staff voiced positive statements and understanding regarding the falls education provided. Noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a safe discharge for 2 residents (Resident #249 and Resident #250) of 5 residents reviewed for discharge. The facility's failure resulted in Resident #249, who was homeless, being discharged to an unknown friend's house who did not allow the resident to stay, Resident #249 then walked to another friend's house who drove him to a motel where Resident #249 resided for approximately 2 months at which time he was evicted from the motel and hitchhiked to another friend's house. Additionally, the facility's failure resulted in Resident #250 being home alone where she sat in a wheelchair for 4 days in urine and feces before she was provided incontinence care by a home health staff. Resident #250 was hospitalized 6 days from discharge with multiple Stage I and Stage II pressure ulcers on her buttocks and sacrum from prolonged exposure to urine and feces. This failure placed Resident #249 and Resident #250 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F660. The facility was cited at F660 at a scope and severity of J. The Immediate Jeopardy began on 6/16/2023 and was removed on 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy Discharge Planning dated 5/1/2012, showed, .The Social worker or designee will be responsible for discussing discharge plans with each resident .admitted to this facility .Updates and changes in discharge plans can occur at any time, due to change of condition or resident changing plans. These changes will be documented in the general notes of the Electronic Medical record .Social Services responsibilities for assisting resident for discharge to home may include .setting up follow-up appointments, setting up home health, and assist in acquiring health related equipment, etc . Review of the facility policy Discharge Against Medical Advice dated 5/1/2012, showed, .To assure that the resident .understands their actions. Encourage the resident .to discuss their motivation for wanting to leave the facility. Every attempt to resolve their concerns should be made and this should be used only as a last resort. Inform the resident .of the possible complications of their discharge action .Document the discharge including any reasons given .Anytime someone discharges Against Medical Advice [AMA] and the facility believes this is an unsafe discharge, Adult Protective Services [APS] must be notified . Resident #249 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's nurse's progress note dated 12/29/2022, showed, .Patient arrived to facility via [by] ambulance at 4 pm [4:00 PM]. He is alert and oriented to self and place but not time . Review of Resident #249's comprehensive care plan dated 12/30/2022, showed, .I have a physical functioning deficit r/t [related to] cognitive decline . Review of Resident #249's comprehensive care plan showed an update on 1/6/2023, for, .I have a physical functioning deficit r/t cognitive decline, repeated falls with need for assistance with personal care and abnormalities of gait and mobility . Review of Resident #249's Nurse Practitioner (NP) note dated 3/31/2023, showed, .Nurse update. Stable. Pt seen in bed- sits up easily. Pt reports desire to go the hell home as soon as therapy is completed . Review of Resident #249's Psychiatric (Psych) NP noted dated 4/4/2023, showed, .Pt [Patient] on MD [Medical Doctor] Board r/t [increased] forgetfulness .highly attention seeking [with] no c/o [complaints of] sleep appetite .concerned [with] d/c [discharge] .Practitioner Orders .Vitamin E 400u [units] po [by mouth] qd [every day] r/t cognition, continue reality grounding . Review of Resident #249's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating he had moderate cognitive impairment. Further review showed no active discharge planning had occurred for the resident. Review of Resident #249's comprehensive care plan showed an update on 4/10/2023, for, .The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia .cue reorient and supervise as needed . Further review showed no documentation of discharge planning. Review of Resident #249's NP note dated 5/29/2023, showed, .Nurse reports stable. [up] [with] walker, goes out on passes [with] family .Dementia .Forgetfulness . Review of Resident #249's Psych NP note dated 6/6/2023, showed, .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple comorbidities . Review of Resident #249's involuntary discharge notice dated 6/6/2023, showed, .Place where resident is going .[homeless shelter] .Date Nursing Home Provided Notice and the Proposed Move .Nursing home gave the resident these pages on: 6/6/2023 .Nursing home wants to move resident on: 7/6/2023 .The resident can choose to move before the 30 days is up. This is up to the resident .Reason for discharge or transfer .You did not pay your bill from the nursing home. The nursing home already told you this and the nursing home gave you time to pay .You got better. And you do not need care in a nursing home now .You have an outstanding balance that you have not paid. You did not pass a [NAME] [Preadmission Evaluation], meaning you are not medically eligible for Medicaid to pay for long-term care in a skilled nursing facility for you. You do not require a nursing home level of care . Further review showed the Administrator, the Physician, and the resident all signed on 6/6/2023. Review of an email sent from the Ombudsman to the Administrator dated 6/6/2023, showed, .[the Administrator] I have reviewed the involuntary Discharge Notice tendered to [Resident #249]. In no uncertain terms may you consider discharging [Resident #249] to [homeless shelter]! It is not now nor will it ever be a safe discharge location . Review of an email sent from the Administrator to the Ombudsman dated 6/6/2023, showed, .We'll void the notice and continue to work with [Resident #249] as we have been for months until a different discharge location can be obtained . Review of Resident #249's Medication Administration Record dated 6/1/2023-6/16/2023, showed the resident had received medications including B-12 tablet for protein calorie malnutrition, Claritin tablet for allergic rhinitis, Folic Acid tablet for protein calorie malnutrition, Vitamin E tablet for cognition, and Amlodipine Besylate tablet for hypertension. Record review revealed Resident #249 signed a Release From Responsibility For Discharge Against Medical Advice on 6/16/2023 at 5:17 PM. Review revealed the form was also signed by the Administrator and the Director of Nursing (DON). Review of Resident #249's nurse's progress note dated 6/17/2023 (recorded 1 day after the AMA was signed by Resident #249) showed, .6/16/23 Resident returned from LOA [Leave of Absence] and stated he was leaving and would not be coming back to facility. Advised this was an AMA discharge and he would not have prescriptions or HH [Home Health] set up. Continued to say he was leaving and began to pack up belongings. All belongings were packed up by resident and he informed the Administrator he was going to stay with a friend. Resident denied any unmet needs and was advised to follow up with PCP [Primary Care Physician]. Requested transport and the facility provided transport [by the Administrator] to address given by resident . During an attempted telephone interview on 8/21/2023 at 10:55 AM, Resident #249 did not answer telephone and the sureyor was unable to leave message. During an interview on 8/21/2023 at 10:56 AM, Resident #249's Friend #2 stated, .I live in the apartments where he lives . She stated she did not know where he was. She stated Friends #3 and #4 would know more about him than she would. During an interview on 8/21/2023 at 12:16 PM, the DON stated, .he had what he called a wife but was not his wife at another facility .they lived together and got evicted because they would not stop smoking in the apartment . She confirmed it was Friend #1 and stated .I don't know what happened to her .we tried to find him placement but once your evicted from government housing it's very hard to get again . The DON stated Friend #3 was not the one he went home with .Friend #3 did not want to help .I think [the Administrator] was the last person to talk to [Resident #249] .it was late afternoon . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated, .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging and we explained that would be AMA and he didn't care and he started packing his stuff .he thought [Friend #3] would transport him . The Administrator stated the resident said he had a friend that was willing to take him in but Resident #249 did not know the friend's name. The Administrator stated, .[Resident #249] called them on the phone .I heard him talking to them, he was in the front office in the lobby .he went to his room to pack up his things and [Friend #3] left him .he was very frustrated and [Resident #249] called [Friend #5] .he said 'hey I'm gonna need somewhere to stay again' and then [Resident #249] said 'Ok' .he was gonna walk so I asked him not to do that .we could help him with transportation .he did not want an uber .so I took him he told me where to go he did not know the address but he knew the streets .I watched him [Resident #249] go to the door [of the residence where the Administrator and Resident #249 arrived] and his friend took him inside .it was a female . The Administrator stated the resident did not have a home to discharge to and stated, .the only address he gave me was the address to the friend [#249] when I dropped him off . During an interview on 8/21/2023 at 1:30 PM, the Social Service Director (SSD) stated, .we kinda provided him a motel I think .people would pick him up and take him home on the weekends .and he ended up leaving with some other female .we had spoken a couple of times about getting him a place and he was very adamant that he would only live in a house that he didn't want an apartment .it's very hard to find a rental house .those are basically the comments that he made to me . [Resident #249] mentioned if he could get a house that would be nice but he didn't want to live in an apartment . She stated she had worked at the facility since 5/1/2023 and stated she had still been in training at that time [a reference to when discharge for Resident #249 was being pursued] .I was learning a lot during that time .I was stepping in just kinda talking to people .I didn't actively search [for Resident #249 housing] and told him how to apply for section 8 if he wanted it .he had [Friend #1] and [Friend #3] .they would show up and pick him up and take him home for weekends and bring him back and drop him back off .just from my observation of him he probably practiced some unsafe choices .but he appeared capable of caring for himself .he did leave without medical advice but in my mind I wouldn't be concerned that he couldn't fend for himself or care for himself . During an interview on 8/21/2023 at 3:03 PM, Registered Nurse (RN) #1 stated Resident #249 was .forgetful very .his cognition varied from day to day .one day he'd be fine the next day he would not .he got around physically pretty good .he did go on outings with family sometimes . During an interview on 8/21/2023 at 3:08 PM, Licensed Practical Nurse (LPN) #1, stated Resident #249 was .he was very forgetful .he would ask several times a day which way to the courtyard .he would go .they would come get him and he would stay gone .I think he left AMA .he had family that would come in so they might have come in and basically took him. He had [Friend #1] and [Friend #3] that he was close with . During an interview on 8/21/2023 at 3:11 PM, LPN #2 stated Resident #249 was, .alert, confused, more forgetful than confused .physically he ambulated and went out and smoked .called [Friend #1] frequently .she was at a facility also . She stated he could care for himself .he went out some .and from what I understand he was looking for an apartment or whatever .[the Administrator] is the one that come and told me he was here to get stuff and was leaving AMA . During an interview on 8/22/2023 at 8:38 AM, the Administrator stated he had let the Ombudsman know in an email that the facility had voided the notice of discharge and would continue to help the resident find a discharge location. During a telephone interview on 8/22/2023 at 8:44 AM, the Ombudsman Assistant, stated Resident #249, .has a history of alcohol, and drug abuse . He stated his assistant had gone to the facility after their office had received the involuntary discharge notices and talked to the Administrator and the plans were for him to remain in the facility. He stated, .We were going to close the case because there were no discharge plans at the time. The facility told her [the Ombudsman's Assistant] he [Resident #249] had advanced dementia and there were no plans to discharge due to cognitive impairments. He probably wouldn't have been able to make heads or tails out of this involuntary discharge notice .we did not do any additional work on it . The Ombudsman stated he had not been informed by the facility that the resident had been taken to a friend's house and no contact information had been obtained from the friend. Further interview with the Ombudsman's assistant she stated, .There was no way he could care for himself .I had a 30 minute conversation with him and later that day he couldn't remember having a conversation with me .he was admitted to the nursing home because he could not care for himself .he stated the resident had been living with a friend [Friend #1] .the APS Coordinator was very familiar with this case and had worked on it intensively he and [Friend #1] were in the process of being evicted [from his previous home] when he was placed in the nursing home . During a telephone interview on 8/22/2023 at 10:09 AM, Resident #249's Friend #1 stated she had lived with Resident #249 prior to him entering the facility and she still talks to him, .yeah when his phones on, it ain't on right now .he's in motel .no I don't know the name of it . She stated she had not talked to the resident in a few days .I ain't been able to get ahold of him .it's been a few days ago [since she spoke to him] . She stated he had been residing in a motel, .since [name of facility] released him . She stated she did not know who took the resident to the motel, .I think a friend took him . She stated he was able to get his medicine and food. During a telephone interview on 8/22/2023 at 10:26 AM, Resident #249's Friend #4 stated, .I tried to call him yesterday and I didn't get no answer .the last time I heard from him he was in [another town] .I don't know if he's on the street or in jail or what .it rung [the phone] and nobody didn't answer . Friend #4 stated he and Friend #3 had been taking the resident out of the facility on passes .[Friend #3] took him back to [name of town where the facility is located] and went by the social security office to get the paperwork he needed to get in a low rental apartment .when she took him back [to the facility] and he threw a fit and didn't want to get out of the car and once he got out he said he was getting his stuff and leaving and that's when [Friend #3] left him .it was my understanding that the Administrator was gonna help him get an apartment .he called me a couple days later and he was in [another town] and that was the last I heard .he had just got out of the hospital [prior to being admitted to the facility] because he was in DTs [detox] from drinking vodka .I don't know if he's back on it or not .he was getting real forgetful .it's been probably a month since I heard from him A telephone interview was attempted on 8/22/2023 at 10:37 AM, Resident #249 did not answer. During an interview on 8/22/2023 at 1:06 PM, LPN #3 stated Resident #249 did have some confusion, .before he left .he would call and tell people to come get him and he was in the process of looking for a house or something .he was able to dial numbers .used the phone every day .called his [Friend #1] . She stated he had a paper with phone numbers written on it that he used to make phone calls. She stated, .I've never seen him cook but he's got sense to call an order something . During an interview on 8/22/2023 at 1:14 PM, LPN #4 stated Resident #249 .he could remember my name .he would say [LPN #4] bought me [Fast food] .he was ambulatory independent .he was pretty social .he had talked about not wanting to be here for a long time .he might have had some memory problems but he knew to feed himself and bathe himself .he also had friends who would come check up on him .[Friend #1] called 4 to 5 [NAME] a day .and had [Friend #3] that would check up on him . She stated, .he just needed a few reminders .he as able to voice whenever he wanted or needed something .he'd said stuff about he wanted to get out and get an apartment or get out and stay with a friend he was with it so it was hard for him to stay here . She stated she did not feel he could live alone, .no maybe assisted living at most . A telephone interview on 8/23/2023 at 12:01 PM, was attempted, Resident #249 did not answer. During a telephone interview on 8/23/2023 at 1:44 PM, Discharge Care Coordinator (DCC ) #1 stated she had worked at the facility .from march 13th 2023 to June 8th 2023 .I did know the patients name [Resident #249] .he was already on the long term side when I came in and I did the short term [resident discharges] .we didn't have a social worker the majority of the time I was there .there was the only person that did the discharge planning was [the DON] .she had multiple roles .we all were playing dual roles because we were constantly short staffed .she [DON] basically did discharges for us she was more versed .she had a little bit more experience .she kept that [discharge planning] going until we got the social worker in .and she [the Social Services Director] was new too .the best of my knowledge was I trained her a little bit but everybody was kinda new . She stated she had not been involved with Resident #249's discharge planning or discharge and had already quit working at the facility before the resident had discharged . During a telephone interview on 8/23/2023 at 1:52 PM, Psychiatric NP stated she had seen Resident #249, .April 4th 2023 .interviewed in w/c [wheelchair] attention seeking .on 6/6/2023 .forgetfulness .on vitamin for E for cognition .and I didn't titrate up to that .my report from the nurses was forgetfulness concerned with discharge but that was actually from the previous time I saw him on April 4th .was when I started the Vitamin E .continue reality grounding .I don't remember him .my purpose is to make sure they can maintain homeostasis [stability] in the facility . During a telephone interview on 8/29/2023 at 10:53 AM, Resident #249's Friend #4 stated, .he showed up at my door yesterday he hitchhiked from up past [name of a town] .he had made a sign and some girl picked him up and brought him down here .said he'd been sleeping in the woods .he had been staying in the motel [Friend #4 not sure how long Resident #249 was at the motel] .they was some lady that worked up there that was supposed to be getting him an apartment .all he had yesterday when he got here was his blue jeans and a shirt .he said he hadn't ate in 4 days .I gave him a shower and fixed him something to eat and now I don't know what to do .he's definitely got dementia and I don't think he can take care of himself . He stated he and Friend #3 could not let the resident stay at their home and needed references of someone who could help find Resident #249 a place to stay. During a telephone interview on 8/29/2023 at 1:58 PM, Resident #249 stated the facility had told him he could not stay there, .no they told me .my social security wouldn't give them none of my check because they said I wasn't sick enough .after that they told me I could leave at any time . He said he did not know if the facility had tried to help him find a place to live, .they didn't tell me about it but my friend here said that they did .my memory is not good . He stated he had stayed in the motel, .I don't know a few months I got a ride with a truck driver and he brought me here and a girl brought me the rest of the way .well I was gonna walk [from the facility] and the Administrator didn't want me to but one of his people drove me to a friend's house .[Friend #5] [Resident #249] stated he had only stayed at Friend #5's house for about an hour, .not even a day .I went to get a pack of cigarettes and all my stuff was sitting out on the porch . He stated he had not called and asked her if he could stay with her prior to the facility taking him to her house, .no she'd always been a friend I didn't figure she'd mind . He stated after he left Friend #5's house he had walked to another friend and stated, .my memory is not what it was .he had a machine shop about a mile [from Friend #5's house] .it was a friend of mine [who took him to the motel] . He was not sure of that friend's name, .they would feed us, well a friend did, they [the motel] didn't feed us . [Resident #249] stated he had stayed at the motel, .10 weeks or so and he had left the motel, .it's been 3 or 4 days ago .they wanted me to vacate immediately and this county sheriff stuck a 12 gauge in my chest and I'm a little old man with a walking stick and can't see good . [Resident #249] stated from the motel, .I got a ride to [another town] from this truck driver and this girl came and stopped and picked me up and brought me here .they're trying to find me an apartment [Friend #4] is . He stated his social security check, .its direct deposited to [bank] .I've got a card and all I have to do is take my bank card and buy anything with it .it's as good as money .since I've been through this where I can't remember anything they [the bank] give me this card . [Resident #249] stated when he left the facility, .well they told me they just brought me from the hospital and I wasn't a resident .I was just like a ghost in the wood box .when they [the facility] found that they couldn't get my social security and the social security office told them I wasn't sick enough and they didn't like that . he stated he had left the facility, .yes against physicians order APA [AMA] .I don't read and write very well .that girl read it to me . He stated he knew what the AMA meant, .yes that I was on my own they wanted me to leave but I have to sign that paper . He stated he had improved physically while at the facility .I got out of the wheelchair and I use a walking stick now . He stated he did willingly sign the AMA .they [the facility] wanted me to leave and I wanted to leave and I told them I'd sign anything .I've got a flip phone and I got it for $35 a month so I got the phone and unlimited everything for 100 dollars and it comes directly out of my check .it never runs out [of minutes] . He stated he had not been answering his phone in the past few days .it quit working and they [Friend #3 and #4] took the battery out and put it back in and its working . During a telephone interview on 8/30/2023 at 11:59 AM, the Motel Clerk stated the resident [Resident #249] had stayed at the motel .probably 2 months .he can come back anytime .there was a nonpayment of rent from Monday to Friday . She stated he had left the motel on Friday 8/25/2023. She stated she had called an officer to ask him to leave due to non-payment. During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated, .in my note on 3/31 I didn't write anything about him being disoriented or anything he wanted to go the hell home .[homeless shelter] does good work, [homeless shelter] deals with homeless .I wish they [the facility] had talked to the friend but I assume he [the resident] had talked to the friend .that's too bad they [the facility] couldn't have taken him to the hotel . She confirmed the resident living in a motel and hitchhiking to a friend's house .wasn't a good environment . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated, .[Resident #249] had a lot of friends and acquaintances he had a network of people .that he chose to go out on pass with . The Administrator confirmed the resident did not have a home and stated .to my knowledge he didn't have a home .I did not want him to walk .I wanted him to be safe and make sure there was someone there that could assist him .I did not speak with the person [where the Administered dropped him off] . The Administrator confirmed he had not spoken to the person and had not confirmed she was willing to let the resident live with her. He confirmed he did not hear the other persons side of the conversation when the resident made the phone call prior to the Administrator driving the resident to the house. He confirmed he did not know the name or address of the individual he left the resident with and stated .from the conversation I overheard it sounded like he had an agreement .he discharged AMA and I helped provide him transportation to a home . He confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed the resident had not been discharged to a safe environment. During an interview on 9/14/2023 at 2:18 PM, the DON, .in the beginning when he [Resident #249] came I tried to figure out living situations .I tried to talk her[previous apartment manager] into taking him back and they wouldn't do it .looks like the only note I put on him was a discharge . DON stated .he told us he was going to stay with a friend . She confirmed she had not spoken to the friend prior to the facility taking the resident to her house and stated, .I did not speak with her .I did not call APS . Interview confirmed the facility did not follow up to check the status of the resident after discharge, .the follow up we could have done better . Resident #250 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, Cerebral Infarction, Chronic Kidney Disease, Morbid Obesity, Difficulty in Walking, Weakness, and Unsteadiness on Feet. The resident was discharged home on 7/5/2023. Review of Resident #250's Baseline Care Plan dated 5/8/2023, showed, .Anticipated discharge date .[blank] .Anticipated Discharge Destination .Home . Review of Resident #250's comprehensive care plan dated 5/10/2023, showed, .I have a physical functioning deficit with transfer and require assistance of extensive .Transfer/Slide sheet for moving up in bed . Review of Resident #250's admission MDS assessment dated [DATE] , showed the cognitive status section had not been completed. She required extensive assistance or 2 staff members for bed mobility, she was totally dependent for transfers with 1 staff member assistance, she was dependent with 1 staff member assistance for locomotion on and off unit, she needed extensive assistance of 1 staff member for dressing, extensive assistance of 2 staff members for toilet use, and supervision of 1 staff member for personal hygiene. The resident required a wheelchair for mobility. Review of Resident #250's comprehensive care plan dated 5/16/2023, showed, .Self Care Deficit related to CVA [Cerebral Vascular Accident], decreased functional abilities .weakness, Cerebral infarct .Bilateral Halo [flexible bed assistant bar for limited mobility residents]rails to bed for increased bed mobility . Further review showed no discharge plan of care had been developed for the resident. Review of an insurance fax dated 7/3/2023, showed, .Date 7/3/2023 .Reviewer notes .100th day is 7/7 [7/7/2023]. I am assuming she will be transitioning to LTC [Long Term Care-remaining at the facility] .Next review Date .7/7/2023 . Review of Resident #250's Physical Therapy (PT) Discharge Summary dated 7/4/2023, showed, .DC [Discharge] Location .Patient discharged to reside in this LTC [Long Term Care] facility. (pt filed for an extended stay to continue with therapy since pt is still needing extensive assistance to get out of bed and transfer) .Prior living Description .She lives alone and has a few neighbors that help her with apartment cleaning and community errands .Prior equipment .Lift chair/recliner, hospital bed, Rollator, FWW [Front Wheeled Walker], manual chair, electric w/c bedside commode .D/C [discharge] Reason: discharged per Physician or Case Manager .Discharge Recommendations: recommend skilled therapy to continue when insurance coverage approves pt's request for an extension . Review of Resident #250's Occupational Therapy (OT) Discharge Summary dated 7/4/2023, showed, .Patient discharged to reside in this LTC facility. (Pt will remain here, awaiting additional insurance approval) .Patient will be discharging to facility (seeking additional approval to stay here) as she is not ready to discharge home (needing max [maximum] assist with LB [lower body] ADLs and significant assist with transfers (mod [moderate assistance] x [times] 1-2 [staff members]). Patient is making significant gains and would benefit from more skilled therapy services prior to when she eventually returns home. Pt is not safe to discharge home at this time even with appropriate DME [Durable Medical Equipment] available . Review of Resident #250's discharge MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating she was cognitively intact. She had a planned discharge to the community. She required extensive assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene, and was totally dependent for bathing. She was receiving scheduled pain medications. She had not had any falls. She received an antianxiety medication, anticoagulants, diuretic and opioid daily. Discharge planning was active, and a referral had been made to the local contact agency. Review of Resident #250's nurse's progress notes dated 7/5/2023, showed, .Alert and oriented X3 with confusion noted. Resting in bed with eyes closed. Bed in lowest position. Able to make needs known. Needs met by staff. No c/o [complaints of] pain at this time. Incontinent of bowel and bladder. Peri care provided. No s/s [signs or symptoms] of distress. Call light in reach . Review of Resident #250's nurse's progress notes dated 7/5/2023, showed, .This writer spoke with transport to arrange resident transportation home as her transport fell through. Transportation s[TRUNCATED]

Based on facility policy review, medical record review, and interview the facility failed to revise a comprehensive care plan timely for 3 residents (Resident #202, #61, and #16) of 28 care plans reviewed. The facility failed to revise interventions to the care plan timely for Resident #202 after the resident's family brought cigarettes and lit them, which led to 3 residents smoking unsupervised on 11/28/2023. Resident #61's care plan was not updated timely after the resident was discovered smoking unsupervised on 11/28/2022. Additionally Resident #16's care plan was not revised timely when he obtained cigarettes from a family, smoked cigarette unsupervised on 11/28/2022, attempted to bring cigarettes into the building on 4/19/2023, and tried to burn a staff member on 4/20/2023 with a lit cigarette. The facility's noncompliance placed Resident #202, #61, and #16 in Immediate Jeopardy. (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations were notified of the Immediate Jeopardy for F657 on 9/18/2023 at 6:10 PM, in the conference room. The facility was cited Immediate Jeopardy at F657 (J). The Immediate Jeopardy began 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated on-site by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Comprehensive Care Plan dated 5/1/2012, showed .The interdisciplinary care plan is implemented to guide health center care staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident .Interdisciplinary team develops resident focused goals . Review of the facility policy titled Care Plans dated 10/2021, showed .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument- instructions to complete the Minimum Data Set (MDS) assessments] manual guidelines .Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change . Review revealed Resident #202 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Patient's Noncompliance with other Medical Treatment and Regimen, Acute and Chronic Respiratory Failure with Hypoxia, and Schizoaffective Disorder Bipolar Type. Review of Resident #202's care plan dated 4/21/2022, revealed the resident was at risk for smoking related injury related to smoking independently. Review of the care plan revealed, .Complete smoking safety assessment per Center guideline .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Review smoking guideline with patient and or family .Storage of smoking material per Center guideline . Continued review revealed the resident's care plan was not revised timely after the smoking incident on 11/28/2022. Resident #202 was discharged from the facility on 3/8/2023 and the resident's care plan was not revised timely. (Revised 3/22/2023, 14 days after the resident was discharged from the facility). Review of Resident #202's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status Score of 15 which revealed the resident was cognitively intact. Review of Resident #202's Activities note dated 11/28/2022 revealed, .This AD [Activity Director] saw this resident out in the courtyard with two other residents[Resident #61 and Resident #16] smoking .I explained to them that it was not the designated smoking time and they couldn't be smoking unsupervised .This resident said she understood .I then went inside and reported it to the nurse on [the name of the hall] and the ADON [Assistant Director of Nursing] . Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder Bipolar Type, Anxiety, and Acute Chronic Diastolic Heart Failure. Review of Resident #61's Care plan dated 7/8/2021, revealed the resident was care planned for smoking related injury related to smoking independently. Review of interventions revealed, .Provide smoking apron while smoking if needed, she is safe to smoke without one but can request one if needed .Assist to and from Designated Smoking Area .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking assessment per Center policy Assessment .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Continued review revealed Resident #61's care plan was not revised timely after the smoking incident on 11/28/2022. The resident's care plan was not revised timely (Revised 9/4/2023, 280 days after the smoking incident on 11/28/2022). Review of Resident #61's quarterly MDS dated [DATE], revealed the resident had a BIMS of 9 which indicated the resident was moderately cognitively impaired. Review of Resident #61's Activities note dated 11/28/2022 revealed, .This AD saw this resident out in the courtyard with two other residents smoking .I explained to them [Resident #61, #202 and #16] that it was not the designated smoking time and they couldn't be smoking unsupervised .I asked her [Resident #61] to put the cigarette out and she did so .This resident said she understood .I then went inside and reported it to the nurse on [name of hall] and the ADON . Review revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Acute on Chronic Diastolic Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Peripheral Vascular Disease, Major Depression Disorder, and Chronic Kidney Disease. Review of Resident #16's Care plan with a date initiated 2/20/2020, revealed the resident was care planned for at risk for smoking related injury related to being a smoker. Review of interventions in place revealed, .Assure smoking material is extinguished prior to patient leaving smoking .Complete smoking assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review revealed Resident #16's care plan was not revised timely following the smoking incidents on 11/28/2022, 4/19/2023, and 4/20/2023 (18 days after the smoking incident on 11/28/2022, 82-83 days after the incident on 4/19/2023 and 83 days after the incident on 4/20/2023). Review of Resident #16's Activities note dated 11/28/2022 revealed, .This AD saw this resident out in the courtyard with two other residents [Residents #202 and Resident #61] smoking a cigarette unsupervised and not at designated smoking times .I went outside explained to this resident that is was not time to smoke [that it was not the time to smoke] and told him to put thecigarette [the cigarette] out .He then told me to leave him the [explicit] alone and go back inside .I told him I would when the [he] put the cigarette out he then threw it in the flower pot still lit .I put the cigarette out while he was telling me to leave it alone .I then went inside and reported it to the nurse on [name of the hall] and the ADON . Review of Resident #16's quarterly MDS dated [DATE], revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. Review of Resident #16's quarterly MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. Review of Resident #16's Activities note dated 4/19/2023 revealed, .[Name of Resident #16] .was seen by multiple other residents put a cigarette in his shirt pocket .He then went into the facility .[Name of medical records personnel] was smoking the residents at this time and informed me of him having the cigarette .I stoppedhim [stopped him] in the front hall I could visibly see the cigarette .I said to him that he could not have the cigarette .that he needed to give it to me .He said it was broken and he was going tofix [to fix] it .He said I don't have a lighter I have a broken cigarette .He continued to argue about not giving to me but did eventually hand me the cigarette .The cigarette was not broken I took the cigarette out to the box realizing that it wasn't one of [Resident #16's] own cigarettes .The other smokers said that another female smoker gave him the cigarette . Review of Resident #16's Activities note with an effective date of 4/20/2023 revealed, .I was doing the 10am [10:00 AM] smoke time on 4/20/23 [2023] . [Name of Resident #16] came out he is currently out of cigarettes he went to another resident and tried to get her to give him her cigarette I stopped her [name of resident unknown] and explained to them that they cannot share cigarettes he told me I needed to go mind my own business .He then rolled over [in his wheelchair] near the bench .I then went to let some other residents back into the facility .When another Male resident rolled by him and handed off a half smoked cigarette [another resident gave Resident #16 his lit cigarette he had smoked] .I immediately went over and held my hand out and told him to give me the cigarette he then attempted to burn me with the cigarette .I told him not to burn me .I explained again why they aren't suppose to share cigarettes and told him again to give me the cigarette he hit it again [smoked the cigarette again] and then handed it to me . During an interview on 9/13/2023 at 12:43 PM, the AD stated she was walking by the courtyard window in the hall near the dining room area on 11/28/2022 and entered the courtyard and observed Resident #61 in the courtyard with 2 other residents smoking a cigarette. The AD stated she asked all 3 residents how they had lit their cigarette. The AD stated, .They [Resident #202, #61, and #16] gave me a non answer they said they just did [in answering how they were able to light their cigarettes] .They put cigarettes out in ashtray .I reported it to Nurse [the AD could not recall the nurse's name] on [name of hall] .She told me to make a note in each chart .I made a note in all residents' chart .That was the first time I caught residents [Residents #202, #61, and #16 smoking unsupervised] . During an interview on 9/13/2023 at 3:19 PM, LPN #1 revealed she was Resident #61's nurse. The LPN stated, .Care plan used to guide the resident's care .We update the care plan so we can give the correct care to residents .Care plans should updated with a change in the resident . During an interview on 9/13/2023 at 4:33 PM, Housekeeper #2 stated, . Residents still finding ways to sneak in cigarettes out to the courtyard .Since been here .an ongoing issue [residents obtaining cigarettes] .I randomly see them resident smoking .Issues smoking half cigarettes .unsupervised like [Resident #16] he has been caught multiple times [smoking unsupervised] .I told nurse can't remember nurse .I caught [Resident #16] smoking unsupervised early June 2023 .He had a half cigarette in his hand in the morning . During an interview on 9/14/2023 at 8:22 AM, the Administrator stated, .We treat the incidents of smoking unsupervised or violation of smoking, resident holding on to cigarettes not disposed in trashcan .We write in the progress notes .He [Resident #16] was discussed in 9/2023 he had cigarette in his possession .Problems related to smoking typically discussed with the interdisciplinary team [IDT] team. The Administrator stated [Resident #16] was discussed in morning meeting [morning stand up meeting] and [with] IDT .Discussed with care plan updates . During an interview on 9/14/2023 at 9:02 AM, and review of Resident #16, #61, and #202s care plan, LPN #12 stated, .There are occasions when residents caught smoking unsupervised on both shifts . The LPN confirmed Resident #16's care plan related to smoking was not revised timely following the incident on 11/28/2022 (Resident #16's care plan was not revised until 12/16/2022 18 days following the unsupervised smoking incident on 11/28/2022). The LPN confirmed Resident #16's care plan was not revised timely following the incidents on 4/19/2023 and 4/20/2023 (82-83 days following the incident on 4/19/2023 and 4/20/2023). The LPN confirmed Resident #61's care plan related to smoking dated 7/8/2021was not revised timely following the incident of Resident #61 smoking unsupervised on 11/28/2022 to include interventions of observing the patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, patient to not have cigarettes or smoking material on person, and assure smoking material is extinguished prior to the patient leaving the smoking area. The LPN stated Resident #202's care plan was not revised timely on 3/22/2023 (Resident #202 was discharged on [DATE] the resident's care plan was revised 14 days after the resident was discharged ). The LPN stated .All 3 residents [Residents #16, #61, and #202] involved in 11/28/2022 smoking incident care plans were updated related to smoking but revised late . During an interview on 9/15/2023 at 3:16 PM, the DON confirmed Resident #202, #61 and 16's care plan was not revised timely following the incident on 11/28/2022, when Residents #202, #61 and #16 were out smoking unsupervised. The DON stated, . [Resident #61's] care plan should have been updated to prevent reoccurrence of any concerns related to smoking and to inform staff what occurred .They [Resident #202's family] her family gave the cigarettes to [Resident #202] and she passed them out to the other to residents [Residents #16 and #61] . The DON stated she did not know how the resident's cigarettes were lit on 11/28/2022 and their safety was at risk due to not being supervised by the facility. The DON stated, . They could have caught on fire or got burn .It should been updated [care plan] sooner following the incident on 11/28/2022 .[Resident #16] care plan should have update with review of smoking policy and education, and interventions added related to incident on 11/28/2022 sooner not timely done .The care plan should have been updated from incident 4/19/2023 .[ Resident #16] got a cigarette already lit from another resident who was smoking and attempted to burn the AD . The DON confirmed Resident #202, Resident #61 and Resident #16 care plans should have been revised with interventions after each incident to prevent reoccurrence. The DON confirmed not updating or revising Residents #16, #61, and #202 care plan related to smoking placed the residents at risk for harm or injury. During an interview on 9/18/2023 at 8:54 AM, the Medical Director (MD) stated, .Care plan should cover all ADLs [activities of daily living] if smoking we should recognize and think forward on what needs to be done .think ahead how to prevent burn and fire and should be put in care plan . The MD confirmed residents smoking unsupervised care plans should be revised timely by the facility. The MD stated, . [Resident #16's] care plan should be updated [revised timely] .If someone [Resident #16] being aggressive like that [attempting to burn staff] .The care plan should have been updated [revised] to reflect [the] incident of him [Resident #16] trying to bring in[a] cigarette from outside in courtyard[Resident #16 brought a cigarette from the designated smoking area into the facility on [DATE]]. The MD stated care plans guide the residents care and informs staff how to provide care to the resident. The MD confirmed the facility failed to revise Resident #16, #61, and #202 care plan timely placed the residents at risk for harm following the incident of residents smoking unsupervised. Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's in-services and sign in sheets, documentation and interviews showed the Discharge Care Coordinator, MDS Nurse, and Unit Managers were in-service on 9/19/2023 on development of individualized care plans and discharge care plans and updating the care plans timely. 2. Review of the facility's in-services and sign in sheets and documentation showed all nursing staff working on 9/19/2023 and 9/20/2023 had been provided the education on individualized and update resident care plans to include change in resident smoking status and noncompliance with the smoking policy as well as education on resident centered interventions implementation. 3. Interviews with the Certified Nursing Assistants (CNA)'s assigned to monitor smoking residents revealed they were aware they were to observe for the resident's ability to smoke safely and review of the current care plan. They were educated and aware if a resident exhibited unsafe smoking practices, they were to stop the resident from smoking and ensure the residents safety. The CNA's were to notify a Licensed Nurse to ensure the resident was reevaluated. 4. Interviews with Nursing staff revealed they were educated to evaluate a resident who exhibited non safe smoking practices and was educated to update the residents care plan with interventions to ensure the safety of the resident and other residents in the facility. 5. Medical record review of resident #16, and 61's care plan revealed their care plans were revised. Review revealed residents had an admission and quarterly smoking assessments were completed and documented. Smoking residents had documented changes related to their safety. 6. Review of all 22 resident's smoking assessments and documentation revealed their care plans had been revised to reflect their noncompliance with the smoking policy and concerns related to smoking. Medical record review revealed Residents #61 and # 16's care plans had been revised related to their noncompliance to the smoking policy and need for supervision. 7. Interviews with various disciplines revealed they were educated if they observed any resident smoking unsupervised, at non designated smoking times, residents refusing to turn in any smoking paraphernalia they were to immediately to notify the Administrator and Director of Nursing. 8. Review of smoking care plan audit tools were utilized by the facility and care plans were updated regarding smoking policy violations by the residents. Noncompliance at F-657 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, and interview, the facility failed to develop an individualized care plan to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure resulted in Resident #74 sustaining a shattered Left Acetabulum (socket of hipbone) and Fracture of the Left Pubic Ramus (Pelvic break). Resident #253 sustaining a Left Femoral Fracture (break in the thigh bone). Resident #149 sustaining a Right Epidural Hematoma (blood accumulation between the skull and the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) and went home on palliative care which placed these residents ( #74, # 253, #149, and #89) in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to develop a discharge care plan for 2 residents (#249 and #250) of 5 residents reviewed for discharge. The facility's failure to provide a safe discharge for a previously homeless resident (Resident #249) resulted in homelessness on the day of discharge. The nursing home Administrator transported Resident #249 to an unidentified friend's home without prior approval from the resident friend. Resident #249 friend did not allow him to remain at her home. Friend #1 did not allow Resident #249 to stay. Resident #249 walked from the friend's home to a second friend's house who drove him to a motel where he stayed for approximately 2 months, was evicted, then hitchhiked to a third friend's home, and Resident #250 was discharged on [DATE], the resident was discharged home in her wheelchair and was left saturated in urine and feces for 4 days. Resident #250 was hospitalized 6 days after discharge from the nursing home and diagnosed with Stage 1 Sacral and Bilateral Buttocks Decubitus Ulcers and multiple small 1-centimeter (cm) areas of Stage II Decubitus Ulcers which placed Resident #74, Resident #249, and Resident #149 in Immediate Jeopardy. The facility failed to develop a care plan to address the use of anticoagulant (blood thinner) medication use for 1 resident (#74) of 5 residents reviewed for unnecessary medications. The Administrator and the Director of Clinical Operations were notified of the Immediate Jeopardy for F656 on 9/18/2023 at 6:10 PM, in the conference room. The facility was cited Immediate Jeopardy at F656 (J). The Immediate Jeopardy began 5/17/2023 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated on-site by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction The findings include: Review of the facility policy Comprehensive Care Plan dated 5/1/2012, showed, .The interdisciplinary care plan is implemented to guide health center care staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident .Interdisciplinary team develops resident focused goals . Review of the facility policy Care Plans dated 8/2012, showed, .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument- instructions to complete the Minimum Data Set (MDS) assessments] manual guidelines . Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Fracture of the Left Acetabulum, Muscle Weakness, Abnormalities of Gait and Mobility, Aphasia, and Congestive Heart Failure. Review of Resident #74's Lift Transfer Evaluation, dated 6/27/2023, showed, Transfer/Walking Belt x 1 team member is required . Review of Resident #74's comprehensive care plan dated 7/21/2023, showed, .The resident is at risk for falls r/t [related to] weakness, hx [history] of falls, unsteady gait, need for assistance with ADLs .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs . Review of Resident #74 nurses progress note dated 7/21/2023, showed, .He has confusion episodes, alert & oriented x1. He is out of bed sitting comfortably in his wheelchair. Requires x2 max [maximum] assist with transfers. He uses wheelchair for mobility .Call light within reach . Review of Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Score (BIMS) score of 14 indicating the resident was cognitively intact. He required extensive assistance of 1 person for bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had no falls prior to admission or since admission. Review of Resident #74's nurses change of condition progress note dated 7/27/2023, showed, .Situation: Resident laying in the floor at the bottom of the bed skin tear to middle of the back. Resident stated he fell out of his wheelchair trying to move to the other side of the bed .Resident laying in the floor at the bottom of the bed skin tear to middle of the back .educated resident to use the call light for assistance . Review of Resident #74's Post Fall Review dated 7/27/2023, showed, .07/27/2023 .[3:00 PM] .Therapy will complete wheelchair use and safety teaching with resident and will assess WC [wheelchair] for safety and possible addition of anti-roll backs [used on wheelchair to prevent it from rolling backwards] . Review of Resident #74's comprehensive care plan showed an update on 7/28/2023, .Fall 7/27/23. Therapy will complete wheelchair safety teaching . Review of Resident #74's Interdisciplinary Team (IDT) meeting note dated 7/28/2023, showed, .Fall 7/27/23 with 2 skin tears. Skin tears treated and orders written. therapy will complete wheelchair use and safety teaching with resident and will assess w/c [wheelchair] for safety and possible addition of an anti-roll backs . Review of an Occupational Therapy Treatment Encounter Note dated 7/28/2023, showed, .Precautions .impaired safety awareness/impulsive .COTA [Certified Occupational Therapy Assistant] instructed patient on how to properly maneuver w/c, lock/unlocked [unlock] brakes and navigating throughout environment with patient demonstrating fair carryover. Falls prevention education provided and importance of reaching out to nursing via call light when he is ready to go to bed . Review of Resident #74's change of condition nurses progress note dated 8/2/2023, showed, .Resident reported to day shift that he fell .Complaints of pain to left hip, discoloration to affected area .NP [Nurse Practitioner] notified and assessed pt .Order received to send to ER [emergency room ] . Review of Resident #74's Post Fall Review dated 8/2/2023, showed, .05:30 .Location of fall .residents room .Prior to fall, patient was .in bed .Physical evaluation .Skin tear .Not witnessed .Immediate actions .[blank] . Review of Resident #74's facility investigation dated 8/2/2023, showed, .Resident reported fall in the bathroom. C/O [complaints of] pain to left hip. Knot noted to outer hip upon assessment . Resident reported to PT [physical therapy] that he fell in the bathroom [time of fall unknown] . Review of Resident #74's NP visit note dated 8/2/2023, showed, .Called to room. Pt. c/o hip [Left] pain. He reports he fell in the bathroom .he is found in bed .Nursing and PT staff are present .He has c/o severe pain to lt. [Left] hip with attempts to move him. He has knot to lt. [Left] outer hip .acute Left hip pain self-report of unwitnessed fall in bathroom . Review of Resident #74's Emergency Documentation dated 8/2/2023, showed, .c/o fall and hitting head but unsure when he fell . Per NH [Nursing Home] pt fell last pm but pat [patient] states it was in the daylight yesterday .Pt does c/o headache and is on blood thinners [medication used to aid with keeping blood clots from forming] .He reportedly is on blood thinners and hit his head. Unknown loss of consciousness as he is somewhat confused to the event . New area of suspected bruising along the left hip has more hyperdense appearance than other areas of edema .The left acetabulum [socket of the hip bone] is fractured, multiple fracture planes, some intersecting the acetabular margin .No evidence of left femoral fracture or dislocation .Impression .The left acetabulum has been shattered since prior examination .Simple fracture to the inferior left pubic ramus [a group of bones that make up part of the pelvis] .Small superfical hematoma along the left outer hip .Medical Decision Making .Acetabular fracture .Pelvic Fracture . Review of Resident #74's comprehensive care plan showed an update on 8/29/2023 (22 days after Physical Therapy identified Resident #74 had a second fall at the facility) for, .Place on contour mattress to assist in not rolling out of bed . During an observation and interview on 9/7/2023 at 9:25 AM, with Resident #74 he stated he had a .broke hip . from a fall. Observation showed the resident's bed was elevated and his call light was not within reach. An observation of Resident 74's room on 9/11/2023 at 1:14 PM, revealed the resident had a contour mattress on his bed. Continued observation showed the resident was in his wheelchair in the day room. During an interview on 9/12/2023 at 1:45 PM, Licensed Practical Nurse (LPN) #5 stated, .[Resident #74's Name] .yes he's a fall risk . She stated interventions in place to prevent falls included, .bed in low position .call light in reach .reminders .frequent checks . LPN #5 stated, .I do remember seeing him in the floor[unknown date for the first fall] but honestly don't remember who found him .he had a skin tear to his back . She stated no one had asked her any more details related to the [first] fall than what she put on the post fall evaluation and the fall investigation. She stated, .therapy will assess .possible for anti-rollbacks my immediate action was getting him out of the floor .we have a fall packet we do . During a telephone interview on 9/12/2023 at 6:11 PM, LPN #10 stated, . The fall interventions in place for Resident #74 were .just making sure his call light was in reach, make sure he's changed and didn't get up to go to the bathroom and stuff, making sure his urinal was in reach, and keeping a check on him .we don't know when he fell . She stated she had never assessed the resident after the fall [unknown date 8/1/2023 or 8/2/2023 Resident #74's second fall]. She stated, .when therapy went to get him .and he complained about hip pain, and they noticed bruises . During an interview on 9/13/2023 at 1:36 PM, LPN #12 stated Resident #74 had been assessed as a high risk for falls on admission to the facility and did not have individualized fall prevention interventions developed. During an interview on 9/13/2023 at 3:27 PM, the Administrator stated falls are addressed by the IDT [interdisciplinary] team. The Administrator stated, .So I have a morning stand up .clinical stand up .currently [LPN #12] .to ensure that the incident is completed appropriately, the investigation is completed thoroughly, and an appropriate plan of care is implemented . During an interview on 9/14/2023 at 11:38 AM, the Administrator confirmed, .fall interventions should be person centered . During an interview on 9/15/2023 at 2:35 PM, the DON [Director of Nurses] confirmed the new care plan intervention of a contour mattress was added to Resident #74's bed, to prevent a fall from the bed, after a second fall was reported on 8/2/2023. The DON confirmed this intervention was not an appropriate intervention since the resident reported he fell in the bathroom. Resident #253 was admitted to the facility on [DATE], with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Myocardial Infarction, Difficulty Walking. Review of Resident #253's baseline care plan dated 3/30/2023, showed, .History of falls .Orient to room/call light .most used items within reach .Bed low position .Visual checks every 2 hours and as needed x 72 hours . Review of Resident #253's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 2 staff for bed mobility and toilet use. Resident #253 was dependent on 2 staff for transfers. Resident #253 required extensive assistance of 1 staff for locomotion on unit, personal hygiene, and dressing. The resident had no falls. Review of Resident #253's comprehensive care plan dated 4/17/2023 showed, .Self-Care Deficit related to .assist X (2) team member/members for bed mobility and repositioning .The resident is at risk for falls r/t Gait/balance, Incontinence, Hemiplegia .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response for assistance . Review of Resident #253's Post Fall Review dated 7/10/2023, showed, .Date and time of fall .7/10/2023 .2:40 .Resident rolled out of bed .Prior to fall .In bed .History of falls .Impaired safety awareness/judgement .Resident has confusion .Resident has laceration to left side of head/forehead. Complaints of left shoulder and back pain .Not witnessed . Review of the facility's fall investigation dated 7/10/2023, showed, .heard resident yell out for help .Went into resident's room where she was lying in the floor beside the bed on her left arm .Resident unable to give description .Left side of head was bleeding and she was complaining of shoulder and back pain . Vitals taken WNL [within normal limits] .Contacted [Ambulance] to take to ER .Injury Type .Laceration .face . Review of Resident #253's hospital Discharge Summary dated 7/24/2023, showed, .Fall from bed .Forehead laceration .Repaired in ER .Left femoral IT [Intertrochanteric] fracture. S/P [status post] . repair .Advanced Dementia .discharge home with home health . During a telephone interview on 8/29/2023 at 8:15 PM, Certified Nurse Assistant (CNA) #7 stated .she [Resident #253] was confused but she kinda knew too she would call me [NAME] [not the CNA's name] . CNA #7 stated the resident did sometimes try to get out of bed without assistance. CNA #7 stated the interventions used to prevent falls for Resident #253 were .we would lower the bed .and call light within reach . She confirmed Resident #253 was at risk for falls. During an interview on 8/31/2023 at 3:02 PM, LPN #12, also the facility's falls nurse stated the interventions used to prevent fall for Resident #253 were, .call light within reach .encourage resident to use for assistance .prompt response to all requests .educate resident family caregivers .encourage to participate in activity that promote .improve mobility .ensure she is wearing appropriate footwear when ambulating or mobilizing in wheelchair .LPN #12 confirmed the resident had no individualized interventions to address her frequent attempts to get up without assist. LPN #12 confirmed resident #253 sustained a fracture from her fall on 7/10/2023. During an interview with the Administrator 9/14/2023 11:38 AM, the Administrator confirmed Resident #253 did not have individualized interventions developed to prevent falls and had sustained harm when she fell on [DATE] and sustained a left femur fracture. Resident #149 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Unspecified Fracture of Right Femur, Unspecified Dementia, Adult Failure to Thrive, Alzheimer's Disease, Unspecified Hearing Loss, Insomnia, and Unsteadiness on Feet. Review of Resident #149's daily skilled Note dated 5/1/2023, .Alert .Disoriented .Decision Making Skills .Severely impaired .Bed mobility .Total Dependence .Transfer .Total Dependence . Review of Resident #149's baseline care plan dated 5/2/2023, showed .FALLS .History of falls .Interventions .bed in lowest position, personal items in reach, call light in hand . Review of Resident #149's comprehensive care plan dated 5/2/2023, showed .I have a physical deficit with transfers .Hoyer Total Lift Large (Green) Sling .Transfer/Slide Sheet for moving in bed .Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, femur fracture, pain, weakness .Extensive assist x [times] 2 team member/members for bed mobility and repositioning . Further review showed no documentation a care plan had been developed to address Resident #149's risk for falls. Review of Resident #149's admission MDS dated [DATE], showed the resident had severely impaired cognitive status. The resident had no behaviors and required extensive assistance of 2 staff members for bed mobility, transfers, dressing, and toileting. Resident #149 had falls in the past month and the past 2-6 months prior to admission. Review showed the resident had a fall with fracture prior to admission to the facility. Resident #149 had no falls since admission to the facility. Review showed no documentation a comprehensive care plan had been developed to address Resident #149's risk for falls. Review of Resident #149's nurses progress note dated 5/9/2023, showed .Resident sitting on her wheelchair peddles [pedals] .Resident finished dinner and attempted to take herself to the bathroom .no injury noted no redness noted . Review of Resident #149's Post Fall Review dated 5/9/2023, showed .6:30 PM . Immediate actions .Assisted resident off of her wheelchair peddles [pedals] and back into her wheelchair. Educated Resident to use call light . Review showed no documentation a comprehensive care plan had been developed to address Resident #149's risk for falls after the fall on 5/9/2023. Review of Resident #149's nurses progress note dated 5/17/2023, showed .After assessing [Resident #149] it was found that she had a laceration to the back of her head, she was bleeding a lot, a cold cloth was held to the back of her head with pressure to help stop the bleeding .orders received to send [Resident #149] to .ER [emergency room ] . Review of Resident #149's Post Fall Review dated 5/17/2023, showed, .20:10 [8:10 PM] .Activity at time of fall .Walking in room .Prior to fall, patient was .In bed .Patient's explanation of how they fell .Pt unable to reply .History of falls .Not witnessed .Immediate actions . Review showed there were no immediate actions documented. Review of Resident #149's emergency room Documentation dated 5/17/2023, showed .unwitnessed fall with bleeding from back of head . Impression .Acute extra-axial hemorrhage right temporal region .concerning for epidural hematoma . Review of Resident #149's emergency room Documentation dated 5/18/2023, showed .Discussed the situation here with the patient's [family members] .They report the patient has advanced age with dementia they do not want surgery .Assessment/Plan .Traumatic epidural hematoma . Review of Resident #149's hospital Palliative Care Consult Note, dated 5/18/2023, showed .96-yo [year old] female with Alzheimer's dementia and cerebrovascular disease, also right femur fracture in April 2023 treated conservatively without surgery .She was transferred 5/18/2023 after fall from standing with epidural hematoma .Per neurosurgical evaluation family declined operative intervention .Problem List .R [Right] Epidural hematoma .Extra-axial intracranial hemorrhage . Review of Resident #149's Hospital Discharge Summary, dated 5/22/2023, showed .Ultimately, patient elected to go comfort care with the help of her family. She was discharged home with hospice on 5/22 [5/22/2023] . During an interview on 8/23/2023 at 3:07 PM, LPN #12 stated .I oversee the falls .making sure that they complete their fall reports .making sure we update care plans and all that stuff . She stated .5/9/2023 .that was her [Resident #149's] first fall so she should have had just the basic general interventions making sure her positioning is good making sure she wasn't in pain or anything that would cause her to want to get up . The LPN stated .generally the care plan gets started on admission and things go over to the Kardex to let the CNAs know pretty much anything they need to know about this person . LPN #12 confirmed Resident #149's fall risk care plan was not developed until 5/17/2023, 8 days after the fall on 5/9/2023. The LPN confirmed the 5/9/2023 fall was from her wheelchair and the intervention listed on the post fall evaluation was .ensure the resident's call light is in reach and encourage the resident to use for assistance as needed the resident needs prompt response . The LPN confirmed the post fall evaluations were not added to the care plan. She stated when a resident falls .we review them in morning meeting, and we talk about them and that's when we put our heads together and come up with an intervention .now that we have an MDS they update the care plan . LPN #12 confirmed after Resident #149's fall on 5/9/2023, the intervention listed on the post fall evaluation to encourage the use of the call light was not appropriate. During an interview on 9/5/2023 at 3:13 PM, LPN #11 stated when a resident has a fall the new intervention would be added to the care plan by LPN #12. During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated it was her expectation for the facility to develop a fall risk care plan for residents who are at high risk. NP stated encouraging Resident #149 to use her call light would not have been an effective intervention if resident had severe cognitive impairment. The NP confirmed when Resident #149 fell on [DATE] and sustained an epidural hematoma she had sustained harm from the fall .yes that is harm . During an interview on 9/14/2023 11:38 AM, the Administrator stated .I attend the IDT meetings where we review falls and discuss interventions . He stated if a resident is at risk for falls it was his expectation for the facility to .develop a care plan intervention and implement it .so we should take account of any hospital records and family or acquaintance interviews as well as our own fall assessment .yeah I do [expect person centered interventions to be developed] . The Administrator confirmed the intervention to encourage use of the call light for Resident #149 was not appropriate. The Administrator confirmed if the facility had completed a thorough investigation of the fall on 5/9/2023 and implemented appropriate interventions the fall on 5/17/2023 could have been prevented. The Administrator confirmed the resident had sustained harm when she fell on [DATE] and sustained an epidural hematoma. Resident #89 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Osteoarthritis, Acute Kidney Failure, Anxiety Disorder, Muscle Weakness, and Cognitive Communication Deficit. Medical record review of Resident #89's admission MDS dated [DATE], showed she had a BIMS score of 99, indicating the resident could not complete the interview. She required limited assistance of 1 staff member for bed mobility, transfers, walking in room, and personal hygiene. She required extensive assistance of 1 staff member for toilet use. Review of Resident #89's care plan dated 7/24/2023, showed . at risk for falls/injury r/t [related to] weakness, poor standing/transfer balance, cognitive deficits. Needs redirection at times for safety. Hx [history] of fall at home prior to admission .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Medical record review of Resident #89's nurse's progress note dated 8/2/2023, showed .Resident was sitting in shower chair while CNC [CNA] was opening door and she leaned forward, and her chair slid out from under her as she landed on her bottom . No injury noted. Medical record review of Resident #89's Post fall review dated 8/2/2023, showed .Date and time of fall .08/02/2023 10:45 [10:45 AM] .to/from shower .Patient's explanation .unable to communicate what happened .Witnessed .Immediate actions .She has been reminded again .her habit of leaning forward in her chair . Medical record review of Resident #89's care plan dated 8/2/2023, showed .[Resident #89] has had an actual fall .Fall 8/2/2023: encourage [Resident #89] to avoid leaning forward when in shower chair . Review of Resident #89's facility investigation dated 8/6/2023, showed .Resident found sitting on floor next to chair .said she was driving a car .Injury Type .Hematoma .Other info .more confusion with dementia. Unable to comprehend instructions with numerous reminders to sit back in chair and call for help . Medical record review of Resident #89's Post Fall review dated 8/6/2023, showed .07:45 [7:45 AM] .chair to floor .Patient's explanation .Sitting in chair and leaning forward as she does ths [this] frequently .Not witnessed .Immediate actions .Assist back to chair. Assessment completed with VSS, and neuro checks completed. Sent to ER for knot on forehead from apparent fall . Medical record review of Resident #89's ER documentation dated 8/6/2023, showed .This morning she was found on the floor and thought she was driving a car. Patient has severe dementia and cannot provide any history .CT scan [x-ray] showed a forehead contusion but no other traumatic finding .Currently do not see indication that she needs hospitalization Medical record review of Resident #89's care plan showed an update for 8/6/2023, .Fall 8/6/2023: Neuro-checks completed. Sent to ER for evaluation of hematoma. Returned from ER with no new orders. Staff to interview patient to further investigate reasoning for leaning forward and communicate with therapy Medical record review of Resident #89's IDT [interdisciplinary team] meeting note dated 8/7/2023, showed .fall 8/6 [8/6/2023] nursing to interview resident on forward leaning posture, perform pain assessment, will communicate findings with therapy . Medical record review of Resident #89's nurse's progress note dated 8/7/2023, showed .Spoke with resident about how she leans forward when she sits and ask her if she was experiencing any back pain. Resident reports that back pain was what got her in the habit of leaning forward while sitting but she does not have pain anymore. Encouraged her to practice sitting back in chair to prevent further falls. Resident agreed. No S&S of pain observed while talking with resident . Medical record review of Resident #89's care plan showed an update on 8/17/2023, for .[Resident #23] has had an actual fall .fall 8/17/2023: Therapy to evaluate for positioning while sitting . Review of Resident #89's facility fall investigation dated 8/17/2023, showed the resident stated .I got to pee . Resident assisted to the toilet and back to her chair safely. Reminded to use her call light for any help . Medical record review of Resident #89's Post Fall Review dated 8/17/2023, showed .Date and time of fall .08/17/2023 .chair to floor .bedroom .sitting in wheelchair in her bedroom .Resident prefers to bend over while sitting. She has muscle weakness and with confusions episodes requires frequent redirections .no apparent injury .not witnessed .Assessed for injury, no injury was noted and reported. Resident then assisted back to her wheelchair. Vitals signs and neuro checks obtained . Medical record review of Resident #89's OT [occupational therapy] progress note dated 8/17/2023, showed .Pt found in floor by OTR and CNA today .OTR educates pt to ensure she alerts staff prior to getting up. Pt with impaired safety awareness, increased confusion and has tendency to attempt to get up on her own. OTR and nursing discuss patient's need for increased supervision and checks with possible need for toileting schedule. No injuries sustained with fall . Medical record review of Resident #89's IDT meeting note dated 8/18/2023, showed .Actual fall 8/17/2023. Therapist to evaluate for seated positioning due to patient forward lean while in seated position . Review of Resident #89's facility fall investigation dated 8/19/2023, showed .Began Am med pass and resident was noted on floor in front of her chair. She was sitting up waiting on breakfast. She is noted for leaning forward while sitting as far as her head can go and at times between her knees. She is reminded consistently to sit up as staff passes her room. All staff aware of hx of falls and have been instructed to due [do] random room checks when passing by or just in the area .Immediate actions taken .VS taken and neuro checks performed, WNL. Incontinent of bowel and bladder. Assisted BTB [back to bed] .xferred [transferred] via ambulance to ER . Medical record review of Resident #89's ER [emergency room ] documentation dated 8/19/2023, showed .Unwitnessed fall with L [left] hematoma from fall this am while eating breakfast .Allegedly, she had fallen from her wheelchair. The patient tells me that she has some mild-to-moderate pain in her mid and low back. She is normally non-ambulatory and wheelchair-bound .DISPOSITION .Discharge .no evidence of traumatic injury .Pt coming from [name of facility] for recent falls. [name of facility] stated patient has dementia, old hematoma on R side of face, new hematoma on L side of face. [unable to determine how many times the resident fell ] . During an interview on 8/29/2023 at 1:07 PM, LPN #9 stated Resident #89 .she has a bad tendency to lean forward, you have to constantly remind her to sit up . LPN #9 confirmed the reminders are not effective due to the resident had a diagnosis of dementia. During an interview and observation with CNA #1 on 8/31/2023 at 10:22 AM, CNA #1 stated Resident #89 was not at risk for falls .no I don't think so .not that I know of, but I don't think so . Continued interview and review of the resident's Kardex [resident care information] showed the resident had a fall on 8/2/2023 and was to be encouraged to avoid leaning forward in shower chair. Further interview and observation of Resident #89 at 10:43 AM, showed the residents seated in w/c leaned all the way over on her knees asleep. Continued interview/observation showed CNA #1 confirmed Kardex/interventions only mentioned to encourage to not lean in shower chair and not for wheelchair. During an interview on 8/31/2023 at 3:02 PM, LPN #12 confirmed Resident #89 was at high risk for falls upon admission. She stated the interventions that were put in place were .call light in reach prompt response educate about safety and reminders encourage to participate in activities and pt to eval and treat as ordered . The LPN confirmed the fall investigation dated 8/6/2023 showed .sitting in chair and leaning forward as she does routinely .it says assessment completed .sent to ER for knot on forehead from apparent fall .[new intervention] staff to interview .communicate with therapy .there was never an outcome as to why she's leaning forward . The LPN confirmed the new intervention did not help to prevent further falls as no outcome was placed on the care plan. The LPN stated the fall on 8/17/2023 .therapy to evaluate for positioning while sitting .and then there was never anything else added

Based on facility policy review, review of facility documentation, and interview, the facility failed to maintain competent staff in the kitchen to deliver the evening meal service on 9/3/2023, for 22 residents of 28 residents reviewed. The findings include: Review of the facility policy Department Staffing, revised 9/2017, showed, .The Dinning Services department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective .All employees will be provided with job descriptions and appropriate education and tools for executing their duties . Review of facility document/Menu showed the following: dinner meal for 9/3/2023, garlic herb pork loin, seasoned cabbage, garlic roasted red skin potatoes, dinner roll, and apple crisp. Review of facility document/Mealtimes dated 1/29/2020, showed, .Supper .5:00pm-6:30pm . Further review showed the last tray cart was to be delivered by 6:00 PM. Review of facility document/food delivery service receipt dated 9/3/2023, showed at 7:23 PM the facility ordered (4) 12-piece chicken meals with macaroni and cheese, and mashed potatoes to be delivered to the facility. Review of the facility document/Menu Substitution Log showed on 9/3/2023, the substitution for the dinner meal was fast-food chicken, with macaroni and cheese, and mashed potatoes. Review of facility document/Dietary Inservice, dated 9/5/2023, showed .Topics: How to handle a food emergency . During a resident council meeting on 9/7/2023 at 2:00 PM, Resident #58 and Resident #21 voiced on 9/3/2023, residents on the 500 and 600 halls were served a fast-food chicken dinner meal at 9:30 PM. They stated the kitchen had .ran out . of food and the Administrator had to order out food. The residents voiced no concerns related to having a change in food items from an outside source. During an interview on 9/7/2023 at 3:10 PM, the Dietary Manager (DM) stated .we did have an incident on Sunday [9/3/2023] .we have a meal substitution log we fill out and the RD [Registered Dietitian] signs off on .anytime we change what's on the menu . She stated on Sunday night (9/3/2023) the facility had .a new cook [Dietary Aide #1] who .overserved and ran out of pork and didn't know what to do . She stated training of new cooks .we do 2-3 days of training . She confirmed there was not enough food for the .last 22 people [residents] . She stated the dietary staff tried to call her but .the call didn't go through .they didn't have critical thinking to contact the CDM or another cook .[the Administrator] got [fast food chicken meals] . She stated once she became aware of the situation on 9/3/2023, she went to the facility to make sure all the remaining residents were provided the consistency [included pureed] they required. She stated Dietary Aide #1 had received a day and a half of training prior to 9/3/2023 and was left to provide the supper meal. She stated Dietary Aide #1 had been a dietary aide for several months and was transitioning to cook. She stated the Sunday evening cook was a no call/ no show. She stated .I talked to the evening shift [employees] to see if they felt confident that they could do it [serve the evening meal] . She stated she talked to the evening shift .several times prior to them running out of food. The DM stated .she was not trained on what to do if she ran out of food . She stated apparently there were issues with the delivery of the [chicken meals] as well .when I got here it was here .I got the message at 8:22 PM .I was here by quarter til 9 [9:00 PM] .we probably were done serving 5-10 min after 9:00 PM . she stated on a normal day .we start tray pass at 5:00 PM and are done by .6:30 PM . She stated the other 2 dietary employees who were on duty at the time were Dietary Aide #2 and stated .he is brand new . and Dietary Aide #3. She stated Dietary Aide #1's phone was not working that night and she had used Dietary Aide #3's phone to call. She stated they attempted to call her at 6:33 PM but the call did not go through. She stated .when I called here [the facility] at 8:23 PM, nobody answered . During a telephone interview on 9/12/2023 at 8:12 PM, Dietary Aide #1stated .I'm a dietary aide but that day I was a cook .I had never cooked the food .[the DM] had [Cook #1] go over the cards [dietary tray cards that show what each resident's diet is] with me .the guy that was supposed to work [as the cook] was a no call no show .I had never been trained and its usually a mandatory 3 day training .I never got to train .I came in as an aide but when I got to work the cook was a no call no show .I called [the DM] and she said [Dietary Aide #3] was coming in to help .[the DM] was supposed to come in and cook I had maybe 15 min to learn the cards and that's just not enough time I've never even run the puree machine .[Cook #2] had called in the day before that [9/2/2023] and it was told that if he didn't come in [the DM] would come in and cook .later [the DM] said to [the CDM] that she thought I had been trained .because she did scheduled me 2 times [to train with another cook] she stated she had not been able to train on either of those days. She stated Cook #1 had cooked most of the meal but she had been left to cook the remaining food .she cooked everything but the cabbage and the potatoes .I had the pork .I had plenty of it left over but I didn't know what to do when I ran out of everything else .ran out of cabbage and potatoes and at the time I didn't know how to make pureed .I ran out of my sides and my puree stuff .probably because I used tongs and were not supposed to use the tongs .now I know what to use the scoops .but I'd never trained as a cook . She stated the DM had not asked her if she felt comfortable to serve the evening meal .no I called her and asked her about the puree machine and she said I could face time her but she didn't call me to see if I was ok .I called and told her .[Cook #2] didn't show up .I was under the impression for [Dietary Aide #3] to come in a help as dietary aide .[Cook #1] said that she [the DM] told her [Cook #1] that I was gonna be the cook .she [the DM] asked [Cook #1] if she could stay and cook and she couldn't .we tried to call [the DM] .[Dietary Aide #3] had called [the Administrator] and told him [they had ran out of food] .[the Administrator] said he was gonna order [fast food chicken] for the last 22 people .it had to be about 6:35 [PM] because I called [the DM] at 6:33 [PM] and she didn't answer She stated meals were delivered to the facility at .about 9:05 [PM] .almost 2 hours late .they took over 2 hours .right after the [fast-food chicken] came is when [the DM] showed up .it was a delivery service [delivery service name] . She stated the DM helped once she arrived to the facility .with the pureed because I didn't know how to do it She stated once the food arrived it had taken .probably about 25 min [to get it served] . During an interview on 9/13/2023 at 2:44 PM, the DM stated .the only thing that she cooked was the potatoes and the cabbage .she has knowledge from being a dietary aide .everybody knows how to serve we cross train in this kitchen .she's had her training for dietary aide .as a dietary aide they have to know the scoops because they do they fruit . The DM stated .she's [Dietary Aide #1 been here for 2 months and if she had done what she had been told she would have been fine . She confirmed Dietary Aide #1 had been scheduled to train with a cook on 2 different dates but had not been trained. She stated no one had notified her that Dietary Aide #1 had not been able to train on the 2 dates she had been scheduled to train with a cook. She stated she had not asked Dietary Aide #1 if she had trained on those days when she spoke to her on 9/3/2023 before allowing to her cook the sides for the evening meal and to serve the evening meal. The DM confirmed Dietary Aide #1 had not served a meal before that day. She confirmed the Dietary Aide had not had a competency checkoff to perform duties of a cook. She confirmed the dietary aide did perform tasks such as cooking potatoes and cabbage and serving the main meal that she had not previously performed. She confirmed she had been made aware of the scheduled cook being a no call no show. DM confirmed Dietary Aide #1 had not been trained by a cook on the 2 days she was scheduled to be trained and she had not been made aware. During an interview on 9/13/23 at 2:45 PM, Cook #3 confirmed she had never trained Dietary Aide #1 to perform duties of a cook. During an interview on 9/13/2023 at 3:27 PM, the Administrator stated on the evening of 9/3/2023 .I was called by kitchen staff and they communicated that they had run out of cooked food .I asked how many people did we still lack and she said 22 people, they had attempted to notify the DM but had not gotten in touch with her yet so informed them that I would be sending food and they would still be responsible for making sure the correct texture went to the residents .I was told that the day cook had cooked all the food but a new staff member had overserved .I think she [Dietary Aide #1] was still in training . The Administrator confirmed it had taken longer than he thought to get food delivered for the residents. The Administrator confirmed it was the DM's responsibility to ensure the kitchen staffing is covered appropriately and it was not his expectation for the DM to allow an employee to perform duties without training. He confirmed he had not been made aware Dietary Aide #1 had not received training to perform duties of a cook prior to 9/3/2023. He stated . they should be competent .there should be a competency checkoff . The Administrator stated it was his expectation the DM should .get another cook or come in herself .

Based on patient education material review, observation, and interview, the facility failed to ensure 1 resident (Resident #58's) of 3 residents reviewed had their dialysis access assessed and the findings documented every shift. The findings include: Review of ESRD NCC (End Stage Renal Disease National Coordinating Center) patient education material titled, It Only Takes a Minute to Save Your Lifeline Arteriovenous Fistula First Program undated showed, .Listen .When you place your access next to your ear, you hear a sound. And it sounds the same as the last time you checked it [normal] .Feel .Thrill: a vibration or buzz in the full length of the access. Pulse: slight beating like a heartbeat. Fingers placed lightly on the access should move slightly [normal] .Pulsatile: The beat is stronger than a normal pulse. Fingers placed lightly on the access will rise and fall with each beat .The directions presented in this material is considered best practice for the assessment of an internal dialysis access. Healthcare staff will utilize a stethoscope to listen to the dialysis access. Resident #58 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Seizures, and Diabetes. Review of the comprehensive care plan dated 11/15/2022 , revealed .has an alteration in kidney function related to ESRD [End Stage Renal Disease] and requires dialysis treatments at [dialysis clinic name] M-W-F [Monday, Wednesday, Friday] @ [at] 11:15AM .Observe thrill [feeling for a pulsation] and bruit [swooshing sound when listened to with a stethoscope] daily and document findings .report abnormal findings to Physician . dated 1/11/2023. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitive intact. Further review revealed the resident required supervision assist of 1 staff member for bed mobility, toileting, dressing and transfers. Resident required Renal Dialysis. Review of the current Physician's Orders for 9/2023 showed .[Dialysis Clinic Name] .M-W-F [Monday, Wednesday, Friday] .Observe for swelling, increased warmth, bleeding, pain, and redness at HD [hemodialysis] shunt [dialysis access] site .Remove pressure dressing W/I [within] four hours of patient's return from HD [hemodialysis] .Observe access site .If bleeding occurs, apply pressure with clean gauze for 5-10 mins [minutes], if bleeding persists, continue to hold pressure and notify MD/NP [Doctor/Nurse Practitioner] . No order was in place to check Resident #58's dialysis access for thrill and bruit. Review of Resident #58's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 8/2023 and 9/2023, showed no area on the record for the opportunity for nursing to document the thrill and bruit assessment of Resident #58's dialysis access. During interview on 9/11/23 at 9:40 AM, the nursing staff stated the went to dialysis clinic early today. During an observation and interview on 9/11/2023 at 10:20 AM, Licensed Practical Nurse (LPN) #4 opened Resident #58's electronic medical record revealed no documentation of a physicians order in the resident's medical record for the nursing staff to assess the thrill and bruit of the dialysis access every shift. LPN #4 proceeded to enter the order in the electronic medical record (MAR) for nursing to assess the dialysis access every shift for thrill and bruit. (best practice protocol) LPN #4 stated .I don't know why it [the order to assess the dialysis access] was not in here [the MAR] . LPN #4 stated there was documentation on the dialysis sheets sent to the dialysis facility and returned back to the nursing home. The dialysis sheets were only used [used to assess the dialysis access site for thrill, bruit, redness, swelling and infection.] on the days Resident #58 went to the dialysis center for treatment. (not best practice, not timely) No other documentation was found for assessing the residents' dialysis access. During an observation and interview on 9/11/2023 at 10:30 AM, revealed Resident #58's Unit Manager/LPN #12 stated the facility nursing staff observed Resident #58's dialysis access site for redness, swelling, and bleeding. The MAR and Treatment Administration Record showed no documentation of assessing Resident #58's dialysis access for redness, swelling, bleeding or the presence of the thrill and bruit.

Based on medical record review, observation and interview, the facility failed to provide 1 resident (#33) with podiatry care of 28 residents reviewed for ADL (activities of daily living) care. The finding include: Resident #33 was admitted to the facility on [DATE] with Contractures, post distant Cerebral Vascular Accident with residual Hemiplegia, Chronic Obstructive Pulmonary Disease, and a history of Alcohol Abuse. Review of Resident #33's annual Minimum Data Set (MDS) dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and requiring extensive assistance of 2 persons for bed mobility, and extensive assistance of 1 person for toileting and personal hygiene. Observation and interview with Resident #33 on 9/6/2023 at 10:30 AM, showed he was lying in bed on his right side and when asked if he had any complaints, the resident spoke of needing to have my toenails cut . Observation revealed the toenails of both feet were thick, yellow, long and misshapen. During an interview with the Social Services Director (SSD) on 9/11/2023 at 3:45 PM, she confirmed Resident #33's last documented Podiatrist appointment was on 5/27/2021. The SSD stated the nursing staff kept a list at the nursing station for residents who required a podiatry appointment. The SSD stated Resident #33 had a Podiatrist appointment scheduled for 8/8/2023. Interview confirmed the resident did not receive podiatry care on the scheduled date of 8/8/2023 due to an issue with payment. Review revealed at the time Resident #33's trust fund reflected he had a balance of approximately $14,300 dollars in his account on 8/8/2023. During an interview on 9/11/2023 at 3:55 PM, the Director of Nursing (DON), confirmed Resident #33 had not received podiatry care as scheduled on 8/8/2023.

Based on medical record review, observation and interview, the facility failed to assist 1 resident (#14) with obtaining glasses of 28 residents reviewed. The findings include: Resident #14 was admitted to the facility to the facility on [DATE] with diagnoses including Congestive Heart Failure, Diabetes, Chronic Obstructive Pulmonary Disease, Depression and Anxiety. Review of Resident 14's quarterly Minimum Data Set (MDS) assessment showed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During observation and interview on 09/07/2023 at 10:00 AM, Resident #14 stated she believed her eyesight, especially when watching television, worsened over the last year and thought glasses were prescribed in the last year but she never received them. She stated her insurance should not be a problem. During facility record review and interview on 9/8/2023 at 10:30 AM, with the Social Services Director (SSD), she showed Resident #14 did have an eye exam 9/2022. Interview confirmed the resident's insurance coverage would cover the expense of glasses. Interview revealed, .didn't know why the glasses weren't ordered .

Based on record review and interview, the facility failed to manage the Resident Trust Accounts for 6 residents (Resident #19, Resident #20, Resident #27, Resident #33, Resident #37, and Resident #50) to ensure they did not exceed the allowable Medicaid limit of $2,000.00 and failed to refund personal trust fund monies within 30 days of death for Resident #151, of 36 resident Trust Accounts reviewed. The findings include: Review of the facility's individual Resident Statement Landscape monthly trust accounts showed the following residents' trust accounts contained more than the Medicaid allowable amount of $2,000.00 which could result in the resident being ineligible for Medicaid benefits: Resident #19 $4,061.36 Resident #20 $4649.78 Resident #27 $6904.19 Resident #33 $6071.28 Resident #37 $23,501.10 Resident #50 $5,241.50 Medical record review revealed Resident #151 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Review of Resident #151's Resident Statement Landscape trust report, dated [DATE], revealed Resident #151 had $4,240.95 remaining in the trust fund, paid out to the responsible party on [DATE], 65 days after the allowable 30 days to refund the monies. During an interview on [DATE] at 11:10 AM, the Business Office Manager stated every resident Medicaid trust account should have no more than $2,000.00 and confirmed Resident #19, Resident #20, Resident #27, Resident #33, Resident #37, and Resident #50's trust accounts had more than the $2,000 allowable limit for Medicaid eligibility. Interview confirmed the Business Office Manager had acquired her position 4 months prior and had not addressed the residents' accounts containing greater than the allowable $2000.00 During an interview with the Administrator on [DATE] at 1:45 PM, he confirmed the facility failed to reimburse personal trust fund monies within 30 days after death for Resident #151.

Based on facility policy review, medical record review, facility investigation review, hospital documentation review, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 resident (Resident #1) of 3 residents reviewed for wandering and elopement. The facility's failure placed Resident #1 in Immediate Jeopardy (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #1 was found approximately 50 feet from the facility's main entrance after having gone through 1 locked door and the facility entrance doors. Resident #1 was found in a parking lot on the ground by another resident's family member with a left [CONDITION(S)] that required surgery. In addition, the facility failed to implement interventions to prevent falls for 1 resident (Resident #2) of 3 residents reviewed for falls. The facility's failure to ensure fall interventions were implemented resulted in Resident #2 falling out of bed and sustaining injuries including a fractured rib and hemothorax (blood collection between the chest wall and lungs that can cause the lung to collapse) and actual Harm for Resident #2. The Administrator and Regional Director of Clinical Operations (DCO) were notified of the Immediate Jeopardy on [DATE] at 5:42 PM. The facility was cited F-689 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] and was removed [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] and the corrective actions were validated onsite by the surveyor on [DATE]. The facility's noncompliance continues at a scope and severity of G for monitoring the effectiveness of the corrective actions. The findings include: Review of facility policy Elopement dated ,d+[DATE], revealed .to establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Process .Newly admitted or readmitted residents are assessed for elopement risk .after admission when a newly identified elopement risk is identified the risk of elopement evaluation is completed to determine interventions .an individual plan is established and implemented to mitigate that risk . Review of the facility's procedures for Elopement Prevention and Investigation, undated showed .Risk factors .impaired cognition .anxiety .inability to recognize familiar people .smoking .psychiatric history . Review of the facility policy Falls dated ,d+[DATE], showed .to establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .when the risk is identified the intervention is documented on the care plan and on the caregiver guide .the identified intervention is initiated and monitored for effectiveness . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged home on [DATE], with diagnoses including [CONDITION(S)] ([CONDITION(S)], group of diseases that cause airflow blockage and breathing-related problems), Palliative Care, Nicotine Dependence, Anxiety, and [CONDITION(S)] (brain disease that alters brain function or structure). Review of Resident #1's Elopement Risk Assessment (ERA) dated [DATE], showed .1. Is the resident physically able to leave the building on their own? If no, disregard the remaining questions . Continued review showed No was selected on the questionnaire, which indicated the facility assessed the resident was not physically able to leave the facility and was not at risk for elopement. Medical record review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The MDS showed Resident #1 required limited assistance of 1 staff member with bed mobility, transfers, dressing, toileting, and activities of daily living (ADL's). The section indicating if the resident exhibited wandering behaviors was not completed. Review of Resident #1's Comprehensive Care Plan, dated [DATE], showed .at risk for falls related to .decreased safety awareness .balance disturbance .weakness .uses walking aids and w/c [wheelchair ] . Review of a Weekly Nursing Note dated [DATE], showed .resident up in wheelchair propelling self through hallways without difficulty. Alert and oriented to person, place and time . Review of an ERA dated [DATE], showed the facility assessed the resident was not physically able to leave the facility and was not at risk for elopement. Medical record review of a Clinical Health Status Evaluation dated [DATE], showed Resident #1 was at risk for falls with risk factors including .impairment in lower extremity strength .displays restlessness, lethargy, wandering or resistive to care . Review of a nursing Progress Note dated [DATE], showed Resident #1 was .alert with periods of confusion today. Ambulating about the facility and going outside for smoke breaks. Resident has not been taking her oxygen with her today . Review of a Weekly Nursing Note dated [DATE], showed Resident #1 was alert and oriented, understood others, and was able to make herself understood. Continued review showed the resident was able to independently transfer, utilized a wheelchair to self-propel and displayed no wandering behaviors. Review of a nursing Progress Note dated [DATE], showed .Resident awake and very confused. Will not wear oxygen. Was walking very shaky down hallway .Resident repeatedly taking oxygen off and attempting to get up and leave. Kept yelling 'Daddy, don't do it .no, I don't want to take that medicine' . Continued review showed no documentation an ERA was completed. Review of a facility Minor Injury incident report dated [DATE], showed .resident confused and attempting to ambulate in room .skin tear right inner wrist .mental status .very confused. Does not recognize family members .continues to transfer self without assistance. Refusing medications . Continued review showed no documentation an ERA was completed. Review of a Hospice Narrative Note dated [DATE], showed .patient seen this visit .she is clear and coherent for the moment but this changes on a moments notice per staff, she is having paranoia that people are trying to kill her, exit seeking at times, convinced her father is laid downstairs in the basement being prepared for burial (he is in fact quite alive). Intermittent delusions . Review of a Psychiatric progress note dated [DATE], showed .CC [Chief Complaint] E&M [evaluation and management] for anxiety, adjustment d/o [disorder] VH [visual hallucinations] .consulted [with] Hospice .refuses to take [medications] at times .delusional, exit seeking . Medical record review showed no documentation an ERA had been completed since [DATE] and Resident #1 was not identified as being at risk for elopement. Review of the facility Fall investigation documentation dated [DATE], showed .staff alerted this nurse that resident fell outside on the concrete .'I fell outside to look for Daddy' .injury .left trochanter (hip) .Staff alerted this nurse to resident lying outside on concrete. Alert to person. Neuro checks WNL [within normal limits] Resident stated she was 'going outside to look for daddy' and fell .sent to [named hospital] .for treatment . Review of facility timeline documentation dated [DATE], showed .6 PM [Resident#1] noted in hallway .6:15 PM [Resident #1] outside waiting on her dad and fell team onsite .50 ft [feet] from center .appropriate clothes and footwear .weather 80's and sunny .alert and oriented x [times] 3 .verified with her dad that he let her know he was on his way . Review of hospital Surgical Documentation dated [DATE], showed Resident #1 was diagnosed with a .left displaced femoral neck fracture [hip fracture] pathologic secondary to [CONDITION(S)] . and underwent a left hip hemiarthroplasty (hip fracture procedure used to replace half of the hip joint). Review of Resident #1's Comprehensive Care Plan updated on [DATE], showed .s/p [status post] falling outside waiting on father: I am at risk for elopement d/t [due to] not being able to make good safety decisions . Continued review showed interventions included .walk with me outside as I allow .walk with me through the unit as I allow . Can this paragraph above be removed or do you think they are needed? Review of an ERA dated [DATE], showed .1. Elopement Risk .Is the resident physically able to leave the building on their own .[checked] yes .2. Is the resident cognitively impaired .[checked] yes .3. Does the resident have impaired decision making skills .[checked] yes .5. Is there a history of wandering or elopement .[checked] yes .If there are any Yes answers to questions ,d+[DATE], further evaluation by the IDT [interdisciplinary team] .[checked] yes .Based on Risk assessment, is resident at risk .[checked] yes .wandering without exit seeking or desire to leave. Wandering is purposeful. Interventions had been affective [effective] . Review of facility investigation documentation dated [DATE], showed .Resident [#1] fell in the parking lot, she stated she was going outside to wait for her father who was coming to visit .this was verified .she is alert an oriented and able to make needs know [known]. She is able to ambulate independently, sometimes uses her walker or wheelchair. She is able to open the door to go outside, she is able to push the code to exit .Investigation Summary .She is able to leave the building, she is able to go out the door that is coded, she is aware of the code .care plan will be updated upon return, she will be educated about no longer leaving the building without assistance .Actions taken post investigation .she is alert and oriented .she admitted knowing the code and how to get out the door. She realizes that she should not have gone to the parking lot to look for her dad. She agreed to not leave the building without telling someone and signing out . During an interview on [DATE] at 12:31 PM, the Administrator stated .[Resident #1] was alert and oriented .she would come out here (lobby) .she knew how to do the code .she would wait for family .she could walk with a walker independently she was able to walk around the building .have coherent conversation .father was coming to get her .was not an elopement risk . During an interview on [DATE] at 2:20 PM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #1 on [DATE]. The LPN stated Resident #1 had .intermittent confusion quite often .she did walk around her room a lot . The LPN said Resident #1 was steady on her feet when she had her wheelchair to help her ambulate and if she was wearing her oxygen. The LPN stated when Resident #1 refused her oxygen, her oxygen saturation rate (blood oxygen level) would drop within a few minutes and .would say things I would have to question . The LPN stated Resident #1 was not exit seeking but would go out to smoke every day and walk around the building. The LPN stated the resident never left building by herself but .[family] would sign her out for the day . The LPN stated she was made aware Resident #1 was found outside the facility .around 6:00 PM .dinner trays were being passed .aides are pretty much .staying busy .I was working on my cart .remember her coming out in the hall .no chair or oxygen .told her to put on her oxygen .get her chair .seen her go back in her room .did not see her come back out .at 6:15 PM .[Certified Nursing Assistant (CNA) #2] came running in .told me [Resident #1] is in the parking lot .[LPN #2] and [CNA #2] were out there . The LPN stated .2 family members but not her family members . were also outside. LPN #1 stated she observed the resident lying on the concrete with her wheelchair cushion under head .already had EMS called . The LPN further stated .[Resident #1] leaves so much with her family she probably thought it was ok .heard after the fact [her father] was on his way here .[Resident #1] didn't tell me [she was going outside] because I would have went with her . During an interview on [DATE] at 3:11 PM, CNA #2 stated she was not Resident #1's CNA but had passed Resident #1 in the hallway on [DATE], while she was taking out trash at the end of her shift at approximately 6:00 PM. CNA #2 stated she asked Resident #1 .where are you going .[Resident #1] always sits outside in courtyard .[Resident #1] said nothing .figured she was going outside in the courtyard . The CNA continued .,d+[DATE] minutes [later] .not more than 15 minutes .was going to the trash can at back of building .[seen] a big truck .commotion .ran over .[Resident #1] was there on the ground .lady and man out there .man was here to visit someone and the lady was passing by and stopped to help .[the] man ran in to get [LPN #2] .couldn't [have] been out there that long .man said he noticed her sitting in the chair .in the waiting room .he said she was sitting right there on her phone .by the time he came back out she fell .[Resident #1] did say she was waiting on her father .earlier in the day . The CNA stated she asked Resident #1 what she was doing outside and the resident replied she could not get service on her cellphone. During an interview on [DATE] at 3:20 PM, Resident #1 stated on [DATE], she was confused and apparently attempted to put the code in to get out to the lobby and then the front door but was putting in the wrong number (the facility code to exit into the front lobby was posted at the keypad). Resident #1 confirmed she .knew the code .was on the wall . but a couple had been leaving and let her out the door. Resident #1 stated she could not remember much except that she fell , broke her hip, and remembered why and how she exited. Resident #1 denied her father was on his way to the facility, rather she thought there was a cult in the facility and wanted to go home .in my mind I was trying to get home .trying to get away from the cult . Resident #1 stated she has [CONDITION(S)] and when she does not wear her oxygen, she gets confused. She stated she was not wearing her oxygen or using her wheelchair when she fell outside on [DATE]. During an interview on [DATE] at 9:46 AM, when asked if staff knew where Resident #1 was on [DATE], at the time the resident was outside in the parking lot, the Administrator stated .I can't necessarily answer that .the nurse knew her father was coming . During an interview on [DATE] at 2:25 PM, the Psychiatric Nurse Practitioner (NP) stated on [DATE], the Hospice RN had informed her of something related to Resident #1 and exit seeking but stated she could not recall the details. During an interview on [DATE] at 4:23 PM, the Director of Nursing (DON) stated she was aware Resident #1 knew the facility code to exit into the front lobby .went outside to wait for her dad . The DON confirmed she .Never saw [Resident #1] with any exit seeking behavior .did she move around the facility yes . The DON stated the resident was not at risk for elopement because she always had a destination and never wandered aimlessly .would go from her room to courtyard .snack .sometimes if family was coming, she would come up here [lobby] and wait . The DON was not aware if staff were aware of Resident #1's whereabouts at the time she eloped from the facility on [DATE] .I don't know . During an interview on [DATE] at 5:00 PM, the Regional Clinical Director of Operations (CDO) stated the facility was .not a jail .we don't lock people up .her choice and right to be able to make some of those decisions .[Resident #1's] dad was on his way .decided to go and meet him .I don't think she told anybody she was going [outside] .they knew she was going with her dad . During an additional interview on [DATE] at 10:52 AM, the CDO stated if a resident had confusion and could not recognize family after having been alert and oriented, a new ERA should have been completed .I would have . During an additional interview on [DATE] at 1:30 PM, the Hospice RN stated she visited the resident on [DATE], and at that time the resident was delusional and reported people were trying to kill her. The RN stated Resident #1 was worried about her dad. She stated she talked with the NP on [DATE] but does not recall ever using the words exit seeking. The RN stated the resident required supervision and should not be left alone to go outside from a medical equipment standpoint and because the resident had episodes of confusion and delusions related to [CONDITION(S)]. During an interview on [DATE] at 1:42 PM, CNA #5 confirmed she cared for Resident #1 on [DATE]. The CNA reported Resident #1 was her usual self .earlier in the morning, but in the afternoon, she was confused .going up and down the hall and the nurse kept telling [Resident #1] to put her oxygen on . The CNA confirmed she did not know the resident's father was coming to visit that day and did not know Resident #1's whereabouts on [DATE], when they found the resident outside in the parking lot. During an interview on [DATE] at 2:30 PM, the Medical Director stated he was Resident #1's physician and did not believe the resident was at risk for elopement. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] (chronic disease affecting the central nervous system), [CONDITION(S)] (condition in which bones become weak and brittle), Functional [CONDITION(S)] ( inability to move due to medical condition), and History of Sudden [CONDITION(S)]. Resident #2 expired in the hospital on [DATE]. Review of Resident #2's Comprehensive Care Plan dated [DATE], showed the resident was at high risk for falls with interventions that included .follow facility fall protocol . Continued review showed an update on [DATE] .I have a physical functioning deficit .slider and 2 staff members for bed mobility . Review of Resident #2's MDS dated [DATE], showed the resident had a BIMS score of 15, indicating the resident was cognitively intact. Continued review showed Resident #2 was totally dependent on two or more staff for bed mobility, dressing, personal hygiene, transfers, and toilet use. Review of a Nurse Progress Note dated [DATE], showed .Resident [#2] fell out of bed to floor .resident was lying in bed on right side, bed was elevated and staff left resident to go get a brief. Resident stated the air mattress inflated and pushed her out of bed. There were no witnesses to event. Resident was lying flat of [on] back beside bed, Neck was across metal base for overbed table. Resident complained of headache, left rib pain, and hip pain. EMS [Emergency Medical Services] called and resident not moved until EMS arrived .sent resident to [named hospital] for evaluation and treatment . Review of a Nurse Progress Note dated [DATE], showed .EMS here, patient boarded and taken out via stretcher Review of the facility's fall investigation dated [DATE], showed the nurse was called to Resident #2's room and found the resident lying on her right side with the bed elevated.CNA left resident to go get a brief and upon returning to room just before she entered she heard resident yell 'ow' and a big crash. Resident was noted lying in floor on . Continued review showed the resident stated .'the air mattress inflated and pushed me out of the bed and I fell ' .no visible injury but complained of pain .alert and oriented .staff left bed elevated, left resident lying on right side and left resident unattended .Immediate actions .assessed resident and called EMS. Did not move resident until EMS arrived. Re-educated staff on never leaving a resident in bed with bed elevated, using 2 staff members for care . Review of the facility's Investigative Template dated [DATE], showed .I [Administrator] interviewed [CNA #1] and asked if there was a sling or sheet under the resident, [CNA #1] stated no, she was in the process of changing [Resident #2's] brief. [CNA #1] stated she had to go get the brief .asked if [CNA #1] notices if the mattress was inflated or deflated, she stated she did not notice. [CNA #1] stated she placed the resident in the middle of the bed. On her right side .stated the resident usually doesn't move .stated the resident was on her back when she came into the room. [CNA #1] stated she was out of the room for approximately 30 seconds . Further review showed Resident #2 was transferred to [named hospital] for treatment of .hemothorax and rib fractures . Review of EMS documentation dated [DATE], showed .pt [patient] found supine [on back] on floor next to bed pt placed in c-collar, placed on scoop stretcher fro [for] extrication and placed on gurney with crew lift, fully secured, placed in ambulance without incident. Pt vitals taken and o2 [oxygen] sats [saturation] low [92%], placed pt on nasal cannula at 4 liters to positive effect .Normal findings .head, face, neck, chest/lungs, heart . Continued review showed at the time of transport the resident was oriented to event, person, place and time. Review of emergency room documentation dated [DATE], showed Resident #2 .c/o [complains of] L [left] shoulder pain, L hip pain, L rib pain and neck pain .hx [history ] of functional [CONDITION(S)] from MS .patient is good historian .no other complaints at this time . Continued review showed the left shoulder x-ray and brain/head CT [computed tomography] were negative. Further review showed chest CT showed left sided rib fracture with .hemothorax hematoma .patient currently stable on NC [nasal cannula] for [oxygen] .decision is transfer to [named hospital] .discussed with patient: results, diagnosis, and plan for transfer .plan is agreed and understood . During an interview on [DATE] at 5:00 PM, the CDO stated .[CNA #1] walked out for 30 seconds .cart right outside [Resident #2's] door .we checked the bed .[the bed was] belly button height per resident's request .always kept [bed] elevated .[Resident #2] care planned for that [no evidence on care plan resident was care planned for an elevated bed] .had that cast on her leg [previous injury unrelated to a fall] .[Resident #2] told us that it felt like the air mattress inflated and bumped her over .we think her cast shifted .it was the only thing different .[Resident #2] was care planned for ,d+[DATE] assist .no [bed] rails because she couldn't use them .left unattended with an elevated bed [and] on her side .nothing out of the ordinary .would be the same as if she was on her side with q [every] 2 hour turns .why would I think anything different . During an interview on [DATE] at 5:31 PM, when asked how many staff were required to care for Resident #2, CNA #1 confirmed two staff .but you can do it by yourself if you needed to .I was the only CNA on the floor .I left out the room .there were no briefs in the room .[Resident #2] said the air mattress pushed her out the bed .I can't say but that is what she said .left [bed] up high .she had rolled off .she was falling already .ran over to her .other CNA was on lunch . CNA #1 confirmed she did not ask a nurse for help and provided care for Resident #2 by herself on [DATE]. During an interview on [DATE] at 12:14 PM, CNA #3 stated Resident #2 was unable to roll herself during ADL care and required assistance from 2 staff for bed mobility. The CNA stated when asked if she ever provided care to Resident #2 by herself, she stated no .that's dangerous . During an interview on [DATE] at 6:15 PM, CNA #4 stated Resident #2 required at least two staff for bed mobility. The CNA stated she never left Resident #2's bed elevated after ADL care was completed. During an interview on [DATE] at 2:30 PM, the Medical Director confirmed he was notified of Resident #2's fall on [DATE], .My understanding was an aide was changing her .needed some supplies .left room and [Resident #2] fell out of bed .[Resident #2] said something happened with air mattress .believe maintenance checked the bed and couldn't find a problem with it so not really sure what happened .I know she had an air mattress . Continued interview confirmed Resident #2 was not able to assist staff with her ADL care. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] and the corrective actions were validated on-site by the surveyor on [DATE] through interviews, observations, and review of documents. The Removal Plan presented to the survey team documented the following immediate corrective actions implemented: 1. All residents who are physically able to leave the building on their own have the potential to be at risk for elopement thus: On [DATE], the Maintenance Director changed the door code to the main lobby door as it was suspected that Resident #1 used the code to get out of the center. The code change was verified by the surveyor on [DATE]. 2. On [DATE], the Administrator posted new signs on both side front doors and to the lobby exit alerting For the safety of our patients and residents, please do not assist any others in exiting the building without first checking with a nurse. We appreciate your assistance in providing a safe and secure environment. The Administrator, Maintenance Director and manager on duty will monitor for sign placement daily and will be documented using tool #1. The posted signage and audit tool #1 was observed by the surveyor on [DATE]. 3. On [DATE], an adHoc Quality Assurance Performance Improvement (QAPI) meeting was called to discuss the Immediate Jeopardy citation regarding F689 issued, root cause analysis (RCA) and the subsequent immediate plan for removal. AdHoc QAPI meetings will continue to be led by the Administrator daily and documented on tool #2. This was verified by review of the RCA, audit tool #2, review of sign in sheets, and during interviews conducted with the Administrator, Director of Clinical Education, Director of Therapy, and DON on [DATE]. 4. On [DATE], the DCO conducted an in-service with Leadership regarding elopement education. The in-service was verified onsite on [DATE] after review of sign in sheets and after interviews conducted with the Administrator, DON, and DCO confirmed they had been educated on elopement education. 5. On [DATE], the Activities Director called an AdHoc Resident Council meeting to discuss procedures for leaving the premises. A total of 20 residents participated including the Resident Council President. The Activities Director will review this information monthly with the council participants. This was verified onsite after review of facility Ad Hoc Resident Council Meeting Minutes and interviews with 2 residents present at the meeting, including the Resident Council President on [DATE]. 6. On [DATE], the Administrator and the Director of Clinical Education conducted training huddles with team members. 100% of all team members, including contracted therapy, dietary, housekeeping and hospice will receive this education and will not work until they receive it. The Administrator has placed a notice near the timeclock, entrance doors and front lobby desk, stating as such. Contractors have been advised by the Administrator. The Administrator and/or the Director of Clinical Education will make rounds twice daily ensuring each team member on the schedule has received this education prior to working until 100% completed. Review of facility documentation and interviews with 3 CNAs, 1 RN, 1 Dietary Cook, 1 COTA, and the DON confirmed they were re-educated on elopement policies and procedures on [DATE]. 7. The Administrator and/or Maintenance Director will complete 2 elopement drills, one on each shift, daily to ensure all education has been understood utilizing the patient/resident elopement drill worksheet tool #3 that will complete a drill, conduct an after drill review, identify what did not work, any improvements to be made and outcome of drill. Drills will be reviewed in the daily adHoc QAPI meeting. 1 elopement drill was verified onsite, review of 2 additional elopement drill worksheets (tool #3), and interviews conducted with the Maintenance Director, 3 CNAs, 1 RN, including night shift staff, 1 Dietary Cook, 1 Therapy Assistant, and the DON confirmed they participated in an elopement drill on [DATE]. 8. On [DATE], the Director of Nursing Services, Director of Care Coordination, Director of Clinical Education, Licensed nursing assessment coordinator, and Unit manager conducted an Elopement Risk Evaluation on all current residents (total of 95). This was verified on [DATE] after review of all residents at risk for elopement were reviewed for care plan updates, orders, the electronic medical record documentation, and Kardex updates. In addition, observations of residents at risk for elopement on [DATE], showed all care planned interventions were in place. Two up-to-date Elopement books, as well as an Elopement Risk resident list were observed at both Nursing stations on [DATE]. 9. On [DATE], the Maintenance Director conducted function checks on the Wander Guard system. All doors with Wander Guards are functioning properly (the transmitter prevented doors from opening and they alarmed). Observations of all 3 doors with the Maintenance Director on [DATE], confirmed Wander Guard functionality. 10. On [DATE], the Administrator notified the center NP and Psychiatric NP of the IJ and Removal Plan. Review of witness statements and telephone interview with the Psychiatric NP on [DATE], confirmed she was informed of the facility Removal Plan and the facility policy for elopement. 11. On [DATE], the Administrator reviewed the Annual review- emergency operations plan dated [DATE] with no changes made. Interview with the Administrator on [DATE], confirmed she reviewed the emergency operations plan and made no changes. 12. On [DATE], the Administrator composed a letter to all family members available regarding resident safety, elopement risk and helping to monitor the doors. All residents who are their own responsible party will receive a copy and it has been displayed at the front desk. Review of the facility documentation and interviews with 3 residents on [DATE], confirmed the facility provided education to all Power of Attorneys (POAs), including the residents who are their own POA, related to elopement risks and the facility policy. Noncompliance continues at a scope and severity of G for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction (POC).

Based on medical record review, review of facility policy, observation, and interview, the facility failed to identify, assess, and treat pressure ulcers resulting in harm for one (#94) of thirty-four residents reviewed. The findings included: Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was admitted with two unstageable pressure ulcers and the resident was at risk for the development of pressure ulcers. Medical record review of the care plan reviewed on March 29, 2012, revealed "...I need two persons to assist with repositioning to avoid skin friction/shearing..." Medical record review of a Nursing Note dated December 23, 2011, revealed "...On 12-23-11 at 10:45 am resident arrived via ambulance...skin assessment: multiple bruises to upper and lower left and right arm. Large bruises on left and right top of hand. Buttocks red (but) blanchable...Right heel black (pressure ulcer #1)..." Medical record review of a Physician's Order dated December 23, 2011, revealed "[MEDICATION NAME] to (right) heel cleanse (with) wound cleaner then apply [MEDICATION NAME]. Change q (every) 5 days (and) prn (as needed)..." Medical record review of a wound assessment dated [DATE], revealed "...Date first observed: 12-23-11...Location: Right Heel...Stage: Unstageable...Length (in cm (centimeters)) 2.0...Width (in cm) 2.0...Wound bed tissue: Necrotic tissue...Drainage: None...Odor: None..." Medical record review of a wound assessment dated [DATE], revealed "...Date first observed: 12-23-11...Location: Right Heel (pressure ulcer #1)...Stage: Unstageable...Length (in cm) 2.0...Width (in cm) 2.0...wound bed tissue: Necrotic tissue...Drainage: None...Odor:...None..." Medical record review of a wound assessment dated [DATE], revealed "...Date first observed: 12-23-11...Location: Right heel (pressure ulcer #1)...Stage: Unstageable...Length (in cm) 2.2...Width (in cm) 2.0...Wound bed tissue: Necrotic tissue...Drainage: None...Odor: None..." Medical record review of the Care Plan reviewed on March 29, 2012, revealed "...weekly evaluation of wound healing..." Interview on April 18, 2012, at 5:20 p.m., with the Director of Nursing (DON) in the conference room confirmed no wound assessments had been completed from January 13, 2012 until March 29, 2012, and from March 29, 2012, until April 18, 2012, on the right heel (pressure ulcer #1). Medical record review of the treatment record dated December 2011 revealed no documentation of treatment to the right heel pressure ulcer for the month of December, 2011 (pressure ulcer #1). Medical record review of the treatment record dated January 2012 revealed no documentation of treatment to the right heel pressure ulcer (pressure ulcer #1) until January 10, 2012. Medical record review of a Physician's Order dated January 10, 2012, revealed "...D/C (discontinue) [MEDICATION NAME]. Apply skin prep to bilateral heels once daily until healed..." Interview on April 19, 2012, at 8:15 a.m., with the Director of Nursing (DON), in the conference room, confirmed the treatment to the right heel (pressure ulcer #1) had not been initiated until January 10, 2012. Medical record review of a Nurse's Note dated March 6, 2012, revealed "...6 cm x 5 cm unstageable non-blanchable dark area noted on sacrum (pressure ulcer #2) just left of the midline. (Nurse Practitioner) notified. New orders received to cleanse with wound cleanser. Pat dry. Apply [MEDICATION NAME] every 3 days..." Medical record review of a Physician's Order dated March 6, 2012, revealed "...cleanse sacral area pressure sore (pressure ulcer #2) with wound cleanser. Pat dry. Apply [MEDICATION NAME] every 3 days until healed..." Medical record review of a Physician's Order dated March 16, 2012, revealed "...D/C (discontinue) treatment to sacral area (pressure ulcer #2)...Leave sacral wound open to air without any dressing daily..." Medical record review of a wound assessment dated [DATE], revealed "...Date first observed: 3-6-12...Location: Sacrum (pressure ulcer #2) left of midline...Stage: Unstageable...Length (in cm) 6.0...Width (in cm) 5.0...Wound bed tissue: Necrotic tissue...Drainage: Sero-sanguinous...Odor: Mild..." Medical record review of the skin check dated April 18, 2012, revealed, "...(left) buttock (pressure ulcer #2) unstageable 8.1 x 11.4 x 0.9 (with) 2.6 cm tunneling...75% slough..." Interview on April 18, 2012, at 5:20 p.m., with the DON, in the conference room, confirmed no wound assessments had been completed from March 29, 2012 until April 18, 2012, on the sacrum pressure ulcer (pressure ulcer #2). Medical record review revealed there were no wound assessments for a pressure ulcer on the right lateral foot (pressure ulcer #3). Interview on April 18, 2012, at 5:20 p.m., with the DON, in the conference room, confirmed there were no wound assessments on the right lateral foot pressure ulcer indicating when the pressure ulcer was identified (pressure ulcer #3). Review of the facility policy, Wound Management Guidelines, revealed "...The nurse will identify the impairment and stage if indicated...Complete treatment record..." Medical record review of the Treatment Records dated January 2012, through April 18, 2012, revealed no treatment for [REDACTED]. Medical record review revealed the Care Plan reviewed on March 29, 2012, had not been updated to include the pressure ulcer on the right lateral foot. Interview on April 19, 2012, at 8:15 a.m., in the conference room, with the DON, confirmed there were no physician's orders to treat the pressure ulcer on the right lateral foot (pressure ulcer #3). Observation on April 18, 2012, at 9:45 a.m. revealed the West Wing Unit Coordinator providing wound care to the resident's pressure ulcer on the left buttock (pressure ulcer #2). Continued observation revealed the West Wing Unit Coordinator described the wound as follows: Unstageable pressure ulcer measuring 8.1 cm x 5.8 cm x 0.9 cm with 2.6 cm tunneling, with 75% slough. Continued observation revealed the West Wing Unit Coordinator described the wound on the right heel (pressure ulcer #1) and right lateral foot (pressure ulcer #3) as follows: Unstageable eschar pressure ulcer on the right heel measuring 2.3 cm x 1.5 cm, right lateral foot pressure ulcer unstageable eschar measuring 1.4 cm x 1.8 cm. Medical record review of a skin check dated March 22, 2012, revealed "...Red area: center of spine (pressure ulcer #4)..." Medical record review revealed there were no wound assessments for a pressure ulcer on the right upper back (pressure ulcer #4). Interview on April 19, 2012, at 8:15 a.m. with the DON, in the conference room, confirmed there were no wound assessments on the right upper back wound (pressure ulcer #4). Medical record review revealed the Care Plan reviewed on March 29, 2012, had not been updated to include the pressure ulcer on the right upper back. Medical record review of a Physician's Order dated April 15, 2012, revealed "...clean area (right) mid back (pressure ulcer #4) (with) wc (wound cleanser) (and) cover (with) dry dsg (dressing) (change) qd (everyday)..." Medical record review of the Care Plan reviewed on March 29, 2012, revealed "...float heels on my pillow as needed..." Observation on April 19, 2012, at 8:00 a.m, with the West Wing Unit Coordinator revealed the resident lying on the right side in the bed without the heels floated. Continued observation revealed a wound to the upper right back (pressure ulcer #4). Interview at this time with the West Wing Unit Coordinator confirmed was not aware of the wound on the right upper back. Observation on April 19, 2012, at 9:25 a.m., with the Licensed Practical Nurse (LPN) wound care nurse revealed the resident lying in the bed. Continued observation revealed a wound to the right upper back (pressure ulcer #4) described by the LPN wound care nurse as follows: right upper back pressure ulcer eschar measuring 3 cm x 2.5 cm with red peri-wound. The resident was admitted on [DATE], with a pressure ulcer to the right heel. Since admission the resident developed a pressure ulcer on the left buttock identified on March 6, 2012, a pressure ulcer on the right upper back identified on April 15, 2012, and a pressure ulcer on the right lateral foot with no wound assessments identifying when the pressure ulcer developed. The facility failed to consistently assess and treat the pressure ulcers. Medical record review of a Physician's Progress Note dated April 18, 2012, revealed "...Multiple inevitable wounds..." Interview on April 19, 2012, at 9:55 a.m., in the conference room, with the DON, confirmed the Nurse Practitioner was aware of all of the wounds.