Every finding on record at Donalson Care Center

Based on facility policy review, medical record review, facility investigation review, and interview, the facility staff failed to timely notify the responsible nursing staff of a fall for 1 resident, (Resident #9) of 3 residents reviewed for falls. The facility was cited at F 689 at a Scope and Severity of D as Past Non-Compliance. No additional corrective actions are required. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Fall Prevention-Program Policy, dated 7/2026, revealed . A fall refers to unintentional change in position coming to rest on the ground, floor, or onto the next lower surface .or the result of overwhelming external force .The facility utilizes a standard risk assessment for determining a resident's fall needs .The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions .When any resident experiences a fall, the facility will .Assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and updated as indicated .document all assessments and actions . Review of the facility policy titled, High Fall Risk Protocol, dated 7/1/2025, revealed .When any patient experiences a fall, the facility will .Immediately notify the assigned nurse .the nurse will perform a head to toe assessment of the resident and determine any injury .if determined appropriate by the nurse, the staff will safely assist the resident off the floor .implement immediate interventions to help reduce the possibility of another fall .and add the intervention to the care plan .complete the required incident report .Complete a fall assessment tool .Nursing will monitor and document to alert charting every shift for 72 hours .notify physician and family .review the residents care plan and update as indicated .document all assessment and actions .obtain witness statements in the case of injury . Review of the facility policy titled, Notification of Changes, dated 7/1/2025, revealed .The purpose of this policy is to ensure the facility promptly informs .consults with the resident's physician and notifies consistent with his or her authority the resident's representative when there is a change in condition requiring notification .Definitions .Clinical Complications .Need to Alter Treatment .Circumstances requiring notification include .Accidents .resulting in injury .potential to require physician intervention .significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Fracture of Unspecified Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Toxic Encephalopathy, Encounter for Orthopedic Aftercare, Lack of Coordination, Cognitive Communication Deficit, Difficulty Walking, Hypertension, Osteoporosis, Presence of Artificial Left and Right Knee Joints, and Personal History of Transient Ischemic Attack, and Cerebral Infarction. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Resident #9 required moderate assistance of 1 or 2 persons for activities of daily living (ADLs). Review of the comprehensive care plan for Resident #9 dated 6/10/2025, revised 7/2025, and 8/2025, revealed Resident #9 was considered at high risk for falls, with interventions in place to reduce fall risks present including: fall mats at the bedside, room close to nurse's station, toileting program every 2 hours, low bed, non-skid socks, non-skid strips at the bed side, elevated brake lever to the wheelchair, brightly colored tape to the elevated brake lever on wheelchair, and anti-tippers and anti-rollback to the wheelchair. Review of the facility investigation and witness statements dated 6/29/2025 revealed on the evening of 6/28/2025, sometime around 8:00 PM, CNAs A and B found Resident #9 seated on the floor of his room in front of a chair near the bedside. CNAs A and B lifted Resident #9 from the floor and placed him in a wheelchair without notifying Registered Nurse, (RN) C of the fall. Resident #9 was then moved to the nursing station in his wheelchair by the CNAs after the resident's spouse left for the evening for monitoring. Resident #9 remained at the nursing station until approximately 11:00 PM without complaints, then was put to bed by RN C who was unaware Resident #9 had fallen and who had not completed a physical examination of the resident. Resident #9 slept through the night without complaints or signs of injury. Further review of the facility investigation and witness statements revealed on the morning of 6/29/2025, at shift change around 6:30 AM, the off-going night shift CNAs (CNAs A and B) reported to the oncoming CNA D Resident #9 was found seated on the floor the night before but again did not notify RN C or the oncoming Nurse, Licensed Practical Nurse (LPN) E of the incident. Continued review revealed on 6/29/2025 around 7:30 AM, after arising, Resident #9 complained to LPN E of headache and slight neck discomfort. LPN E administered Tylenol to Resident #9, then after speaking with CNA D, around 8:30 AM learned of the reported fall the night before. LPN E immediately notified the facility nursing leadership of the situation, assessed Resident #9 for injuries, notified the attending physician, and responsible party the situation, and transferred Resident #9 to a local hospital via ambulance for further evaluation. Review of nursing progress notes for Resident #9 dated 6/29/2025 at 8:45 AM, authored by LPN E revealed, the resident complained of pain to the back right side of the head. Continued review revealed due to a suspected fall the night before, the resident was transferred to the local hospital emergency room (ER) for evaluation. Review of hospital records for Resident #9 dated 6/29/2025, revealed Resident #9 arrived to the local hospital emergency department (ED) around 9:08 AM. Continued review of hospital ED records revealed .Chief Complaint .FALL .Lost balance while walking .Location of injuries Head, Neck .the injury occurred last night . Continued review revealed .Physical Exam .Vital signs .BP [blood pressure] 144/70 .HR [heart rate] 94, RR [respiratory rate] 16, Pain level 7/10 [seven out of ten] .have been reviewed.Head .no swelling of head .forehead medium sized ecchymosis of the upper central forehead (yellow green, old), no tenderness, Occiput (back of head).tenderness of the lower central occiput, no swelling ecchymosis (bruises) or deformity . Further review revealed there was slight neck pain upon movement and muscle spasm of the neck, with no vertebral tenderness. Review of the hospital radiology records for Resident #9 dated 6/29/2025, revealed a Computer Assisted Tomography (CAT SCAN) was performed and revealed Resident #9 with a Type 2 Odontoid Fracture (a fracture of the peg of the second cervical vertebrae,) with .very mild dorsal (rearward) displacement . Resident #9 was placed in a rigid cervical collar and was transferred from the local hospital to a regional trauma center for further evaluation on 6/29/2025. Review of the Trauma Hospital Records dated 6/29/2025, revealed Resident #9 was admitted to the hospital for evaluation and assessment. The resident's injuries were determined to be nonsurgical in nature, and the resident was discharged back to the facility for continued care on 7/2/2025. During an interview on 8/18/2026 at 12:30 PM, RN C stated Resident #9's fall occurred on a Friday night, sometime before 8:00 PM. RN C stated she was not informed Resident #9 was found sitting on the floor by CNAs A or B at any time during the overnight shift on 6/28/2025. RN C stated Resident #9 had poor safety awareness, and she was aware of his prior fall history, so that evening she had monitored Resident #9 at the nursing station from around 8:00 PM until 11:00 PM, after his spouse left for the evening. RN C stated the resident did not complain of pain or injuries while at the nurse's station and did not observe any visual signs of injury. Resident #9 became tired and wanted to go to bed around 11:00 PM. RN C stated she assisted Resident #9 to bed around 11:00 PM and the resident did not complain of any pain or injuries during the transfer to bed and she had no reason to believe the resident was injured. RC C stated she had monitored the resident throughout the night at least once hourly due to his high fall risk and his close proximity to the nurse's station. RN C further stated Resident #9 had not exhibited complaints of pain, or signs of new injuries, and slept through the night without incident. RN C stated she learned of the alleged fall when she was contacted by the Director of Nursing (DON) around 1:00 PM on 6/29/2025 during the facility's investigation. During an interview on 8/18/2026 at 12:40 PM, LPN E stated she had received shift report from RN C on the morning of 6/29/2026 and had not been advised of any falls or incidents involving Resident #9. LPN E stated around 8:30 AM, CNA D had advised her the off-going CNAs A and B reported to her they had found Resident #9 sitting on the floor the night before and he did not complain of any pain or injuries during the night. LPN E stated on the morning of 6/29/2025, Resident #9 complained to the CNAs he had a headache. CNAs A and B advised CNA D to increase monitoring of Resident #9 due to his reported headache that morning. LPN E stated she telephoned CNA A at home and verified that Resident #9 had been found in the floor the night before. LPN E stated she immediately conducted a physical examination of Resident #9 and notified the attending provider which ordered Resident #9 to be transferred to the hospital for an evaluation. LPN E stated she kept Resident #9 under observation under EMS arrived. During an interview on 8/18/2026 at 1:00 PM, the DON at the time of the incident, (who is now known as RN F, the facility's education coordinator at the time of the state agency investigation), stated she initiated a full investigation of the incident on 6/29/2025 when she was notified of the situation by both LPN E and the ADON. RN F stated CNAs A and B admitted in interviews they had found Resident #9 on the floor on 6/28/2025 and had failed to notify the nurse on duty and stated they had assisted the resident to his wheelchair and moved him to the nursing station for observation. RN F confirmed upon completion of the investigation, the facility determined CNAs A and B violated the facility fall policies and procedure and were terminated. During an interview on 8/18/2026 at approximately 1:40 PM, the Medical Director stated he was aware of the alleged fall of Resident #9 and stated the resident had a history of falls. The Medical Director stated the facility had implemented several fall interventions during the resident's stay at the facility. The Medical Director stated he had been part of the facility's Ad Hoc Quality Assurance (QA) meetings regarding the incident and due to the resident's history of falls, potential Osteoporosis Diagnosis and denial of pain or injury, the facility nursing staff acted promptly when the resident began to complain of pain. The Medical Director stated the resident's injuries healed and was discharged home. In response to the incident, the facility implemented the following corrective actions plans which were summarized as follows: On 6/29/2025 around 9:00 AM the facility launched an investigation into Resident #9's unwitnessed fall and why it had not been documented into the medical records at time of occurrence after Resident #9 was transferred to the hospital for emergent care. On 6/29/2025 the facility identified CNAs A and B had failed to report the Fall to RN C at the time of the occurrence but had reported the fall to the oncoming CNA (CNA D) and identified how LPN E had become aware of the fall as well. All residents in the facility were assessed for injuries, or signs of abuse or neglect with no other negative findings. Residents with BIMS scores higher than 8 who were able to be interviewed were questioned as to any concerns, and none were verbalized. Residents with BIMS scores less than 8 who were cognitively impaired and were unable to be interviewed had skin assessments performed with no negative findings. Written witness statements were obtained from all personnel involved in the incident as well as all personnel in the facility on duty on the night of 6/28/2025. An initial Ad Hoc Quality Assurance (QA) review of the findings to that point were reviewed by the facility ADON and DON who notified facility administration of the situation. On 6/30/2025 the DON conducted direct interviews with all staff involved in the incident and documented them. CNA A and CNA B's written statements were reviewed by the DON, and compared to oral interviews obtained. During interviews with the DON, CNA's A and B did reveal they had lifted Resident #9 from the floor without summoning the nurse to the room at the time of the fall in interviews with the DON but denied they failed to inform the nurse of the fall as was reported to the DON by RN C, who in both her written statement and verbal interview with the DON remained consistent. On 6/30/2025, CNA's A and B were suspended pending outcome of the ongoing investigation. The facility initiated self-reporting of the incident to the State Agency (SA) and all other authorities as required by law upon identification of allegations of possible resident neglect. On 6/30/2025, A second Ad Hoc QA review of the incident was performed which included the facility administrator, DON, ADON and risk management personnel. The facility governing body (hospital) was advised of the ongoing investigation and findings to date. Full review of the investigation findings by the QA committee was planned for the following day. On 7/1/2025 The facility QA Committee which included the medical director, performed review of the findings compiled to date, then formulated a Performance Improvement Plan (PIP) to address deficient practices identified. Mandatory 1 to 1 re-education of all personnel to include the facility fall policies and procedures, notification of changes in condition policy, and abuse prohibition policy were initiated by the ADON and DON at the direction of the QA committee. 1 to 1staff re-education by the ADON and DON continued daily from 7/1/2025- 7/15/2025, until all staff employed by the facility were re-educated on the policies and procedures outlined in the PIP. Personnel who were off duty or on leave at the time of the corrective actions were telephoned and given education by the ADON and DON and were required to sign attestations of teaching upon return to work. Between 7/1/2025 and 7/15/2025 all fall documentation of falls which had occurred at the facility from 6/1/2025 to date were reviewed for completeness and accuracy by the DON, ADON and Risk Manager. No other irregularities were detected. On 7/9/2025 CNA's A and B were terminated for violations of facility policy after human resources review of the investigative findings. On 7/15/2025 the facility QA committee reviewed findings/corrective actions taken to date, reviewed the completion of staff education, and determined no additional new actions were required. Falls and fall related documentation remained on the facility QA agenda as a regularly evaluated performance metric, reviewed by the committee monthly. Daily review of all new falls and related documentation by the ADON, DON, Risk Management, and during the daily morning meetings (attended by clinical department heads), which was already performed as part of the facility routine operations, was maintained in assigned job duties, with no further alterations (daily clinical huddle procedures) required. No irregularities in resident falls or facility documentation for incidents which occurred after 6/28/2025 were detected or required additional actions. The facility notified the resident council president of its actions and scheduled a review of its findings for comments or voicing any concerns by interested resident council members for 7/18/2025. On 7/18/2025 the facility conducted the resident council meeting as planned with no additional negative findings conveyed to the facility. The facility corrective actions were validated onsite by the surveyor on 8/18/2026, by review of facility Quality Assurance Records and Sign in Sheets with permission of the Health System President of Operations. All measures taken by the facility as reported in the PIP were documented as validated by the facility QA team, and members of the facility governing body. The facility routinely evaluated all falls which occurred daily in morning huddle meetings and all falls were routinely reviewed and tracked by the facility QA committee, which were also forwarded compiled QA trends identified to the health system for systematic review/monitoring. The medical director was interviewed on 8/18/2026 and confirmed his involvement in QA review of the incident as reported, the facility PIP, and was aware of corrective actions taken in response to the incident. Clinical record reviews of all falls for Resident #9 as reported in the FRI were reviewed with no other deficient practices noted. Resident #9 recovered from his injuries, completed rehabilitation at the facility and discharged home with home health care services for follow up care on 8/16/2025. Medical record reviews for 2 other Residents with falls (Residents 1 and 7) revealed no concerns/deficient practices identified or cited. Resident observations and clinical record reviews for fall precautions in current residents identified as high risk for falls for surveyed Residents 2, 3, and 4 were conducted on both shifts at intervals throughout the survey with no deficiencies identified. All measures outlined in the facility care plans for those residents were observed to be in place and none of those residents had experienced falls in the prior 60 days, which was corroborated by review of facility incident logs. Review of the personnel files for CNAs A and B verified their terminations in response to the incident. Both employee files contained multiple prior entries related to corrective measures imposed related to job performance prior to 6/28/2025. Both CNAs remained licensed in good standing and were not listed on the abuse registry. Both CNAs had completed all facility required training prior to the incident on 6/28/2025. Review of the personnel file for RN C showed no prior corrective actions, satisfactory or superior performance ratings, no disciplinary history and the nurse was licensed in good standing by the board of nursing and was not listed on the abuse registry. RN C had completed all required facility training and remained employed at the facility in good standing. Review of facility incident logs from June 2025 showed all other falls which had occurred in the facility at the time Resident #9 fell, were documented/investigated appropriately upon occurrence. Review of incident logs from July and August 2026 showed no concerns. Abuse interviews with 4 alert and oriented residents (Residents 2, 3, 4 and 8) and 3 family representatives conducted on 8/17/2026 and 8/18/2026, across both shifts during the survey showed no concerns with Resident Rights, Abuse or Neglect, Resident Safety, Staffing, Notifications of Changes in Condition, Fall Prevention Education, Nursing Services, Clinical Services, Medical Services, Rehabilitation Services, Environment, Administration or Unresolved Grievances. Interviews with 7 clinical staff members conducted on 8/18/2026, included 5 Certified Nurse Aides, 2 Licensed Practical Nurses, and 1 Registered Nurse, who confirmed re-education in June and July 2025 related to the incident with Resident #9, of which they were aware. All staff interviewed could explain the facility abuse policy, definitions of abuse or neglect, and could explain the facility falls prevention and response policies, clinical expectations for documentation/reporting of falls, safety measures, and per facility policy, any resident found in the floor was not to be moved back to bed or chair until assessed by a licensed nurse, and falls were to be immediately reported to the nearest licensed nurse available. All staff interviewed reported they understood it was their duty to ensure timely reporting of all incidents to appropriate supervisory personnel regardless of whether they were assigned as primary caretakers or not and could verbalize their respective chains of command for incident reporting. All licensed nurses interviewed could verbalize the facility expectations related to assessment, documentation of, and incident reporting for falls, accidents, or any other unusual occurrences within the facility, as well as their respective chains of command, and alternatives within the health system for reporting suspected violations should the facility administration fail to investigate incidents/allegations when reported. All personnel were aware of the facility policy related to notification of changes in condition and could define changes in condition reportable as outlined in the policy.

Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure medical information was not visible for 2 residents (Resident #34 and Resident #57) of 83 residents observed for dignity. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/2025, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Maintain resident privacy . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, and Adult Failure to Thrive. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 had severe cognitive impairment. Review of the comprehensive care plan dated 3/01/2025 for Resident #34 revealed no evidence the resident or the resident's representative requested for signage to be posted in the resident's room. During an observation on 3/10/2025 at 9:36 AM, in Resident #34's room, revealed Resident #34 lying in bed with a handwritten sign posted above the television which read, .2-13-25 [2025] .No Briefs to [Resident #34] D/T [due to] groin . Further observation revealed the sign was visible to anyone that entered the room. During an observation on 3/11/2025 at 7:51 AM, in Resident #34's room, revealed Resident #34 lying in bed with a handwritten sign posted above the television which read, .2-13-25 [2025] .No Briefs to [Resident #34] D/T groin . Further observation revealed the sign was visible to anyone that entered the room. During an observation on 3/12/2025 at 8:15 AM, in Resident #34's room, revealed Resident #34 lying in bed with a handwritten sign posted above the television which read, .2-13-25 [2025] .No Briefs to [Resident #34] D/T groin . Further observation revealed the sign was visible to anyone that entered the room. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Diabetes, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #57 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan dated 3/01/2025 for Resident #34 revealed no evidence the resident or the resident's representative requested for signage to be posted in the resident's room. During an observation on 3/10/2025 at 9:39 AM, in Resident #57's room, revealed Resident #57 lying in bed with a handwritten sign posted above the television which read, .1-24-25 [2025] .We are going back to [medicated cream] to [Resident #57's] Buttocks. Please wash skin gently . Further observation revealed the sign was visible to anyone that entered the room. During an observation on 3/11/2025 at 7:54 AM, in Resident #57's room, revealed Resident #57 lying in bed with a handwritten sign posted above the television which read, .1-24-25 .We are going back to [medicated cream] to [Resident #57's] Buttocks. Please wash skin gently . Further observation revealed the sign was visible to anyone that entered the room. During an observation on 3/12/2025 at 9:41 AM, in Resident #57's room, revealed Resident #57 lying in bed with a handwritten sign posted above the television which read, .1-24-25 .We are going back to [medicated cream] to [Resident #57's] Buttocks. Please wash skin gently . Further observation revealed the sign was visible to anyone that entered the room. During an interview on 3/12/2025 at 10:14 AM, the Director of Nursing (DON) confirmed the signs for Resident #34 and Resident #57 was posted by the staff (not requested by the family representative) and was visible to anyone that entered the room. The DON confirmed the facility failed to maintain the residents' dignity and privacy.

Based on facility policy review, medical record review, facility documentation review, and interview the facility failed report an allegation of injury of unknown origin timely for 1 resident (Resident #20) of 5 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, revised 8/12/2024, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Injury of Unknown Source Means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury .Every Employee, contractor and volunteer immediately shall report any .injury of unknown origin .to the Administrator or Director of Nursing immediately . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Gastrointestinal Hemorrhage, Cerebral Infarction, and Hemiplegia. Further review revealed Resident #20 was readmitted to the facility on [DATE] with diagnosis of Displaced Fracture of Base of Neck of Left Femur. Review of a discharge return not anticipated Minimum Data Set assessment dated [DATE], revealed Resident #20 had severe cognitive impairment. Review of a nurse's Health Status note for Resident #20 dated 11/8/2024 at 11:11 AM, the resident was transferred to the emergency department (ED) related to concerns for gastrointestinal (stomach and intestines) bleeding. Review of Hospital A's ED documentation for Resident #20 dated 11/8/2024 at 11:32 AM, revealed the resident presented to the ED with a complaint of vomiting blood. Continued review revealed Resident #20 was admitted to the hospital for further evaluation. Review of a radiology report (Hospital A) for Resident #20 dated 11/8/2024 at 1:46 PM, revealed a computed tomography angiogram (CTA-detailed x-ray) of pelvis (area of the body below the abdomen that is located between the hip bones) was performed and revealed .Destructive changes within the left hip joint with soft tissue swelling around the hip joint and dislocation [out of place] of the femoral head [top of thigh bone] . Review of Hospital A's discharge summary notes for Resident #20 dated 11/9/2024 at 2:50 AM, revealed Resident #20 .was admitted to the hospitalist service for observation for a single episode of hematemesis [vomiting blood]. There was an accidental finding on the CTA abdomen/pelvis of left femoral head dislocation of unknown etiology [cause]. There was left lower extremity shortening and external [outward] rotation on exam . Continued review revealed Resident #20 was transferred to Hospital B for an orthopedic evaluation. Review of Hospital B's history and physical for Resident #20 dated 11/9/2024 at 5:42 AM, revealed the resident was admitted to the facility and orthopedic surgery was consulted. Review of a Hospital B physician progress note for Resident #20 dated 11/10/2024 at 3:12 PM, revealed the resident had been evaluated by orthopedics .patient has severe osteoarthritis of left hip, no evidence of dislocation per orthopedics. No surgical intervention recommended. No further recommendations as per Ortho [orthopedics] . Review of the medical record for Resident #20 revealed the resident was readmitted to the long-term care facility on 11/12/2024. Review of facility documentation revealed Registered Nurse (RN) D became aware of the injury of unknown origin for Resident #20 on 11/8/2024 at 7:00 PM. Continued review revealed the Administrator was notified of the injury of unknown origin on 11/11/2024 at 2:30 PM (2 days and 19.5 hours after RN D became aware). During an interview on 3/12/2025 at 10:20 AM, the Director of Nursing (DON) stated she became aware of Resident #20's injury of unknown origin on Monday (11/11/2024), when she arrived at work and found hospital documentation showing Resident #20 had a dislocation of the femoral head. The DON stated RN D had received a fax that night (11/8/2024) and did not report the injury of unknown origin. The DON then stated .I want to say maybe they [Hospital A] called back to the facility and requested some type of information . The DON confirmed staff were expected to notify her or the Administrator of any injury of unknown origin or allegations of abuse immediately and confirmed the facility's policy was not followed for Resident #20's injury of unknown origin. During an interview on 3/12/2025 at 12:06 PM, the Administrator stated the staff were expected to immediately report any suspicion of abuse and injuries of unknown origin to the abuse coordinator. During a telephone interview on 3/12/2025 at 12:23 PM, RN D stated someone called from the ED or somewhere from the hospital and asked if Resident #20 had had a fall or anything else. RN D stated .I believe [hospital representative] said there was an injury, and we believe [Resident#20's] hip was broken . RN D did not recall if she reported the potential injury of unknown origin to anyone and stated .It's been too long ago . RN D stated she was supposed to notify the .administrative person . if she became aware of an injury of unknown origin.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) to include a new mental health diagnosis for 2 residents (Resident #59 and #18) of 4 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, dated 1/2025, revealed .The facility coordinates assessments with the preadmission and resident review (PASARR) program .to ensure that individuals with a mental disorder .or a related condition receives care and services .Any resident who exhibits a newly evident or possible serious mental disorder .or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review . Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Depression, Anxiety, Insomnia, and Diabetes. Review of a PASRR Level 1 screen outcome for Resident #59 dated 7/27/2023, revealed the resident had 3 mental health conditions diagnosed which included Major Depression, Anxiety Disorder, and Depression Situational. Further review of the PASRR Level 1 screen outcome revealed the resident did not have a neuro cognitive disorder. Review of the medical record revealed Resident #59 was diagnosed with Neurocognitive Disorder with Lewy Bodies (disorder which affects nerve cells in the brain) on 1/12/2024. Review of the medical record revealed Resident #59 was diagnosed with a new mental health condition (Paranoia) on 6/26/2024. Review of the medical record revealed Resident #59 was diagnosed with a new mental health condition (Delusional Disorders) on 11/7/2024. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #59 dated 2/25/2025, scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #59 had Neurocognitive Disorder with Lewy Bodies and had Psychotic Disorder. During a record review and interview on 3/12/2025 at 9:30 AM the Social Services Director (SSD) stated the Level 1 screen outcome for Resident #59 dated 7/27/2023, was the most recent referral to the state designated PASRR agency. During further interview the SSD confirmed the facility failed to refer Resident #59 to the state designated agency for PASRRs after a new neuro cognitive disorder and new mental health conditions were diagnosed . 41782 Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia, and Vascular Disease. Review of a PASRR Level 1 screen outcome for Resident #18 dated 2/12/2021, revealed the resident had 1 mental health condition diagnosed (Major Depression). Review of the medical record revealed Resident #18 was diagnosed with a new mental health condition (Panic Disorder) on 7/14/2021. Review of the medical record revealed Resident #18 was diagnosed with a new mental health condition (Anxiety Disorder) on 10/1/2021. Review of a quarterly MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and exhibited no behavioral symptoms. Further review revealed the resident had Anxiety Disorder and Psychotic Disorder. Review of a PASRR Level 1 screen outcome for Resident #18 dated 3/10/2025, revealed the resident did not have a diagnosed mental health condition and the resident did not have diagnosis of dementia/neurocognitive disorder. During an interview on 3/12/2025 at 8:44 AM, the SSD stated she was responsible for submitting PASRRs. The SSD stated she resubmitted a PASRR on 3/10/2025 for Resident #18 to include the addition of medications. The SSD stated she added the medications but .could not figure out how to add diagnoses . on the PASRR dated 3/10/2025. The SSD stated the diagnosis of Anxiety was added 10/1/2021. The SSD stated the PASARR dated 2/12/2021 included diagnoses of Major Depression and Dementia. The SSD confirmed the PASRR should have been resubmitted after the new diagnosis of Anxiety was added on 10/1/2024. The SSD confirmed Panic Disorder was added 7/14/2021. The SSD confirmed the PASRR had not been resubmitted to include the new diagnoses of Panic Disorder or Anxiety Disorder. The SSD stated PASRR's were to be resubmitted .as soon as she finds out about a new diagnosis .

Based on facility policy review, medical record review, and interviews the facility failed to follow physician's orders related to blood pressure medications for 3 residents (Residents #84, #28, and #9) of 10 residents reviewed for blood pressure medications. The findings include: Review of the facility's policy titled, Medication Administration, dated 1/2025, revealed .Medications are administered by licensed nurses .as ordered by the physician .Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .For medications requiring vital signs, record vital signs onto the MAR [medication administation record] . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hypertension and Cognitive Communication Deficit. Review of the Order Summary Report for Resident #84 revealed an order dated 1/29/2025 for .Losartan Potassium [a medication used to treat high blood pressure] .50 MG [milligrams] .0.5 tablet .by mouth .one time a day related to HYPERTENSION .Hold for SBP [Systolic Blood Pressure] < [less than] 110 . Review of the MAR for Resident #84 dated 2/1/2025 - 2/28/2025, revealed the 2/11/2025 dose of Losartan Potassium was administered by Licensed Practical Nurse (LPN) C with a corresponding blood pressure of 101/60. Review of the MAR for Resident #84 dated 3/1/2025 - 3/31/2025, revealed the 3/3/2025 dose of Losartan Potassium was administered by LPN C with a corresponding blood pressure of 99/67 and the 3/10/2025 dose of Losartan Potassium was administered by LPN E with a corresponding blood pressure of 108/69. Review of the medical record for Resident #84 revealed no adverse outcomes related to receiving the anti-hypertensive medication outside of the ordered blood pressure parameters. During an interview on 3/12/2025 at 12:08 PM, LPN C stated Resident #84 had an order for Losartan 25 mg by mouth daily with parameters to hold the medication for SBP less than 110. This surveyor reviewed the MAR with LPN C and the LPN confirmed she had administered the medication on 2/11/2025 with a SBP of 101. LPN C confirmed Resident #84's SBP was less than 110 and the medication should not have been administered according to the physician's order to hold for SBP less than 100. LPN C stated she had not notified the physician to receive approval to administer. LPN C confirmed she had also administered the medication on 3/3/2025 with a SBP of 99/67 and the medication should not have been administered according to the physician's order. LPN C stated she had not notified the physician to receive an approval to administer the medication. LPN C stated .I think I would have rechecked it before . administering but was unable to recall if she did or what the values were. LPN C stated she was unaware of any adverse effects to Resident #84 because of the administration. During an interview on 3/12/2025 at 12:20 PM, the Director of Nursing (DON) stated Resident #84 had an order for Losartan 25 mg by mouth daily and was to be held for SBP less than 110. This surveyor reviewed the MAR with the DON and confirmed the medication was given on 2/11/2025 with blood pressure of 101/60, 3/3/2025 with blood pressure of 99/67, and 3/10/2025 with blood pressure of 108/69. The DON confirmed the medication should not have been given since the SBP was less than 110. The DON stated she would expect the medication to be held, and a progress note obtained that it was held due to vital signs outside of parameters. The DON stated if a medication was administered despite parameters an order should have been obtained stating it was ok to administer the medication despite the blood pressure being outside the parameters. The DON confirmed Resident #84 had no adverse effects because of the medication administration. The DON confirmed it was her expectation that physician's orders were followed. During a telephone interview on 3/12/2025 at 6:17 PM, LPN E stated if Resident #84's MAR indicated she administered a medication, then .she did . LPN E statedif she had held a medication, the MAR would reflect the medication was held with a reason would be selected from the drop down box. LPN E was aware of the parameters to hold Resident #84's Losartan for SBP less than 110 and stated if the SBP was 108 she would have still given it because .it was just a few points . under the parameter of 110. LPN E stated she had not notified the physician to obtain an order that it was ok to administer the medication with a SBP less than 110. LPN E was unaware of any adverse effects related to administration of the medication outside of the parameters. During an interview on 3/12/2025 at 7:52 PM, the Medical Director (MD) stated he was unaware of physician's orders not being followed related to blood pressure medication parameters. The MD stated the parameters are used as an increased safety measure and the possibility of an adverse outcome was unlikely. The MD was unaware of any adverse outcomes to residents related to the administration of blood pressure medications outside of the ordered parameters and it was his expectation that physician's orders were followed. 48100 Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease, Hypertensive Heart Disease, and Morbid Obesity. Review of the Order Summary Report for Resident #28 revealed an order dated 1/23/2025 for .Metoprolol [a medication used to treat high blood pressure] .50 MG .0.5 tablet .by mouth .twice daily related to HYPERTENSION .Hold for SBP<110 . Review of the MAR for Resident #28 dated 2/1/2025 - 2/28/2025, revealed the 2/18/2025 (8 PM) dose of Metoprolol was administered by LPN I with a corresponding blood pressure of 102/88. Review of the medical record for Resident #28 revealed no adverse outcomes related to the resident receiving the anti-hypertensive medication outside of the ordered blood pressure parameters. During an interview on 3/12/2025 at 6:18 PM, LPN I stated she could not recall if she rechecked the blood pressure for Resident #28 on 2/18/2025. LPN I stated if she documented the medication (Metoprolol) was administered outside of the blood pressure parameters of the SBP <110, then .I gave the medication . LPN I stated on the MAR dated 2/2025, Resident #28's blood pressure reading on 2/18/2025 was 102/88 and confirmed the medication should have been held and not administered. LPN I stated she was unaware of any adverse effects to Resident #28 because of the administration on 2/18/2025. During an interview on 3/12/2025 at 6:30 PM, the DON stated the nurses administering the medications to the residents should follow the physician's order to hold medications for blood pressure parameters if the medication is outside of those parameters. The DON stated the Metoprolol for Resident #28 should have been held and not administered on 2/18/2025 at 8 PM when the SBP was 102 (which was less than the ordered parameter of <110). 50480 Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Heart Attack, Muscle Weakness, and Hypertension. Review of the Order Summary Report for Resident #9 revealed a Physician's Order dated 1/10/2025 for .Metoprolol .50 MG .1 tablet by mouth one time a day related to .HYPERTENSION .Hold for SBP<100 . Review of the MAR dated 2/1/2025 - 2/28/2025, revealed the following: The 2/7/2025 dose of Metoprolol Succinate was administered by LPN E with a corresponding blood pressure of 98/55. The 2/14/2025 dose of Metoprolol Succinate was administered by LPN E with a corresponding blood pressure of 96/56. The 2/17/2025 dose of Metoprolol Succinate was administered by LPN E with a corresponding blood pressure of 92/70. Review of the medical record for Resident #9 revealed no adverse outcomes for Resident #9. During a telephone interview on 3/12/2025 at 6:20 PM, LPN E stated if the MAR indicated she gave the medication, then she did. LPN E also stated if she held the medication (Metoprolol Succinate), she would have documented on the MAR that the medication was held due to parameters. The LPN was aware of the parameters to hold for SBP less than 100, she would have still given it if it was just a few points away from the ordered parameters. The LPN stated she did not notify the physician of the low blood pressure, and stated she did not receive a new order to give the medication. During an interview on 3/12/2025 at 6:34 PM, the DON stated the nurses should follow the physician's order to hold medications for blood pressure parameters if the medication is outside of those parameters. The DON stated the Metoprolol for Resident #9 should have been held and not administered if the SBP was outside of the ordered parameters to administer.

Based on medical record review, observation, and interview the facility failed to ensure a water flush was infusing as ordered for 1 resident (Resident #20) of 3 residents reviewed for tube feedings. The findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Encounter for Gastrostomy (feeding tube), Cerebral Infarction, Chronic Kidney Disease, and Hemiplegia. Review of a comprehensive care plan for Resident #20 dated 11/26/2024, revealed .requires tube feeding .The resident needs total nursing care with tube feeding and water flushes. See MD [medical doctor] orders . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #20 had severe cognitive impairment and received nutrition by feeding tube. Review of a Order Summary Report for Resident #20 dated 12/13/2024, revealed .Free water flush [additional water given to a patient to help meet daily fluid needs] at 60 ml [milliliters]/ [per] hr [hour] x [times] 22 hr/day every shift . During an observation of Resident #20's continuous tube feeding on 3/11/2025 at 5:30 PM, with the Assistant Director of Nursing (ADON) revealed the water flush bag was full of water (1000 ml), was connected to the feeding pump, but the pump had not been programmed to administer the free water flush at 60 ml/hr as ordered by the physician. During an interview on 3/12/2025 at 5:35 PM, the ADON confirmed the continuous feeding pump had not been programmed to administer the free water flush at 60 ml/hr and confirmed the resident was not receiving the free water flush as ordered. The ADON stated staff were expected to ensure the pump was set and was infusing as ordered. The ADON stated she administered medications to Resident #20 around 10 AM on 3/11/2025 and had to place the pump (which infused the tube feeding formula and water flushes) on hold. The ADON stated it was possible the water flushes did not resume when she placed the tube feeding pump off hold after medication administration. The ADON stated the resident was assessed and had no adverse outcome from not receiving the water flushes as ordered. The ADON stated she alerted the medical provider and no additional orders were received. During an interview on 3/12/2025 at 11:15 AM, the Nurse Practitioner (NP) confirmed nursing staff had notified her Resident #20 had not received the water flush as ordered. The NP stated the lack of water flush did not have any adverse effects for Resident #20.

Based on facility policy review, drug manufacturer's information, observation, and interviews, the facility failed to ensure an insulin medication was labeled appropriately to include an open and expiration date in 1 of 4 medication carts observed for medication storage which had the potential to affect 1 resident (Resident #26) of 18 residents reviewed for insulin use. The findings include: Review of the facility's policy titled, Insulin Pen, dated ,d+[DATE], revealed .insulin pens must be clearly labeled with the resident name .expiration date .if label is missing, the pen will not be used .a new pen must be ordered .insulin pens should be disposed of after 28 days .procedure .check the expiration date on the pen .discard if expired . Review of the facility's policy titled, Medication Storage, dated ,d+[DATE], revealed .it is the policy of this facility to ensure all medications housed on our premises will be stored .according to the manufacturer's recommendations . Review of the manufacturer's information for Insulin Glargine, undated, revealed .do not use your [insulin glargine] pen .for more that 28 days after you first start using the pen . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension, and Muscle Weakness. Review of the comprehensive care plan for Resident #26 revised [DATE], revealed the resident had Diabetes with an intervention to administer medications as ordered by the physician. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident received insulin. Review of the Medication Administration Record (MAR) for Resident #26 dated ,d+[DATE], revealed Insulin Glargine (20 units daily) was administered as ordered for 28 days reviewed. Further review revealed the blood sugar levels obtained from [DATE]-[DATE] ranged from ,d+[DATE] and did not reveal any negative outcomes. Review of the MAR for Resident #26 dated ,d+[DATE], revealed Insulin Glargine (20 units daily) was administered as ordered for 11 days reviewed. Further review revealed the blood sugar levels obtained from [DATE]-[DATE] ranged from ,d+[DATE] and did not reveal any negative outcomes. Review of an Order Summary Report for Resident #26 dated [DATE], revealed Insulin Glargine 20 units daily and to check blood sugar levels twice a day. During an observation and interview with the Infection Preventionist (IP) on [DATE] at 8:20 AM, revealed medication cart #6 had 1 insulin pen (insulin glargine) opened (,d+[DATE] full) and not labeled with an opened date for Resident #26. The IP confirmed the Insulin Glargine for Resident #26 was not labeled after opening and she could not verify if the insulin was within the 28-day expiration date. The IP stated the insulin pen was the only insulin pen in the medication cart for Resident #26 and confirmed the resident had received the undated and improperly labeled insulin glargine during medication administration. The IP stated if the insulin pen open and expiration date could not be verified, the insulin should be discarded and not used for medication administration. During an interview on [DATE] at 8:45 AM, the Director of Nursing (DON) stated insulin medications should checked for expiration dates prior to administering the medication and if the open date is not labeled appropriately on the medication, the insulin should not be used and should be discarded. The DON stated the facility should adhere to the manufacturer's' guidelines for expiration dates for the Insulin Glargine of 28 days. The DON confirmed the Insulin Glargine for Resident #26 should have been labeled with an open date and expiration date upon administering the first dose of the insulin. The DON confirmed the undated and improperly labeled Insulin Glargine for Resident #26 should have been discarded and not used for insulin administration. During an interview on [DATE] at 2:59 PM, the Nurse Practitioner (NP) stated Resident #26 did not experience any adverse outcome from receiving an improperly labeled and potentially expired insulin. The NP stated the insulin if used out of date could lose efficacy thus resulting in abnormal blood sugar levels. The NP stated Resident #26's blood sugar levels had been at baseline. During an interview on [DATE] at 3:16 PM, the Pharmacist stated insulins should be dated with an open date when removed from the refrigerator and upon administering the first dose. The Pharmacist stated Insulin Glargine must be discarded after 28 days of opening to ensure the medication's effectiveness and potency. The Pharmacist stated the risk factors associated with administering insulin past the expiration date was poor blood sugar control and had a minimal potential for a serious outcome. The Pharmacist stated the Insulin Glargine for Resident #26 should have been labeled with the date opened to ensure the insulin was used within the 28-day expiration date.

Based on facility policy review, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 resident (Resident #56) of 10 residents reviewed for blood pressure medications. The findings include: Review of the facility's policy titled, Physician's Orders, dated 9/23/2020 revealed .Nursing Personnel will communicate with physicians to assure maximum interpretation and processing .orders related to resident care .provide for their implementation .all medications administered .must be ordered by the physician . Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Anxiety, Hypertension, and Depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Order Summary Report for Resident #56 dated 1/29/2025, revealed .Lisinopril [medication used to treat high blood pressure] 10 MG [milligram] . Give 0.5 tablet by mouth one time a day for HYPERTENSION .Hold for SBP [Systolic Blood Pressure] < [less than] 120 . Review of the Medication Administration Record (MAR) for Resident #56 dated 2/1/2025 - 2/28/2025, revealed the following: The 2/4/2025 dose of Lisinopril was administered by the Infection Preventionist (IP) with a corresponding blood pressure of 110/68. The 2/5/2025 dose of Lisinopril was administered by the IP with a corresponding blood pressure of 112/59. The 2/9/2025 dose of Lisinopril was administered by Licensed Practical Nurse (LPN) C with a corresponding blood pressure of 110/62. Review of the MAR for Resident #56 dated 3/1/2025 - 3/12/2025, revealed the following: The 3/12/2025 dose of Lisinopril was administered by LPN C with a corresponding blood pressure of 111/98. During an interview on 3/12/2025 at 6:13 PM, LPN C stated that she rechecked the blood pressure before giving Lisinopril for Resident #56 if the SBP<120 and she forgot to put the new blood pressure in the system. During an interview on 3/12/2025 at 6:15 PM, with the IP stated she had never given the Lisinopril for Resident #56 if the SBP<120, she would always recheck blood pressure and had failed to record the new one. During an interview on 3/12/2025 at 6:32 PM, the Director of Nursing (DON) confirmed it was her expectation that blood pressures were documented in the medical record accurately.

Based on facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance to residents prior to meals for 5 residents (Residents #4, #12, #59, #49, and #140), of 5 residents observed on 3 of 4 hallways observed for meal tray distribution and failed to ensure staff donned appropriate Personal Protective Equipment (PPE) for 2 residents (Residents #30 and #27) of 6 residents observed on Enhanced Barrier Precautions (EBP), and failed to perform hand hygiene appropriately during medication administration for 1 resident (Resident #73) of 4 residents observed for medication administration. The findings include: Review of the facility's policy titled, Serving a Meal, dated ,d+[DATE], revealed .Prepare the room or serving area for mealtime .and make sure hands and face are clean . Review of the facility's policy titled, Medication Administration, dated ,d+[DATE], revealed .wash hands prior to administering medication .identify expiration date .if expired notify nurse manager .administer medication as ordered in accordance with manufacturer specifications .wash hands . Review of the facility's policy titled, Hand Hygiene, dated ,d+[DATE], revealed .all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .hand hygiene table .condition .before and after eating .before preparing or handling medications . Review of the facility's policy titled, Enhanced Barrier Precautions, dated ,d+[DATE], revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms .Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs, targeted gown and gloves use during high contact resident care activities .All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions .The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .Implementation of Enhanced Barrier Precautions .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include .Changing linens .Changing briefs or assisting with toileting . Review of the facility's policy titled, Handling Soiled Linen, dated ,d+[DATE], revealed .It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection .Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons .Used or soiled linens shall be collected at the bedside (or point of use .) and placed in a linen bag or designated linen receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required supervision or touching assistance for personal hygiene. Review of the comprehensive care plan for Resident #4 revised on [DATE], revealed .ADL [activities of daily living] self-care performance deficit r/t [related to] Activity Intolerance, Confusion .PERSONAL HYGIENE .Assist her with verbal cues . During an observation on [DATE] at 11:50 AM, Certified Nursing Assistant (CNA) A delivered the lunch meal tray to Resident #4. CNA A set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Feeding Difficulties, Muscle Weakness, Lack of Coordination, and Dementia. Review of the annual MDS assessment dated [DATE], revealed Resident #12 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required substantial/maximal assistance for personal hygiene. Review of the comprehensive care plan for Resident #12 revised [DATE], revealed .ADL self-care performance deficit r/t [related to] Dementia .EATING: INDEPENDENT AFTER TRAY SET UP BY STAFF .PERSONAL HYGIENE/ORAL CARE .requires assist x [times] 1 staff for personal hygiene . During an observation on [DATE] at 11:50 AM, the Infection Preventionist (IP) delivered the lunch meal tray to Resident #12. The IP set up the resident's tray and exited the room without offering hand hygiene assistance to the resident. During an interview on [DATE] at 11:52 AM, the IP stated staff were to offer hand hygiene assistance to residents prior to meals. If the resident says yes, we would either offer hand hygiene assistance with hand sanitizer or take them to the bathroom to wash their hands. The IP confirmed she had not offered hand hygiene assistance to Resident #12 and stated .I forgot . During an interview on [DATE] at 12:00 PM, CNA A stated hand hygiene assistance was offered to residents that ate in the dining room and stated .we do not usually do it for the ones that eat in their rooms .we probably should . CNA A confirmed she had not offered hand hygiene assistance to Resident #4 or any other residents she delivered trays to in their rooms. During an interview on [DATE] at 4:25 PM, the Director of Nursing (DON) confirmed residents were to be offered hand hygiene prior to meals with hand sanitizer. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Depression, Diabetes, and Need for Assistance with Personal Care. Review of the comprehensive care plan for Resident #59 revised on [DATE], revealed .ADL self-care performance deficit r/t Weakness .EATING .set up and total assistance .PERSONAL HYGIENE/ORAL CARE .requires assist x1 . Review of a quarterly MDS assessment dated [DATE], revealed Resident #59 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required maximum assistance for personal hygiene. During an observation on [DATE] at 11:56 AM, CNA G delivered the lunch meal tray to Resident #59. CNA G set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Lack of Coordination, and Need for Assistance with Personal Care. Review of the comprehensive care plan for Resident #49 revised on [DATE], revealed .ADL self-care performance deficit r/t Sepsis . Review of a significant change MDS assessment dated [DATE], revealed Resident #49 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required maximum assistance for personal hygiene. During an observation on [DATE] at 11:57 AM, CNA G delivered the lunch meal tray to Resident #49. CNA G set up the meal tray and exited the room without offering hand hygiene assistance to the resident. During an interview on [DATE] at 12:00 PM, Resident #49 stated the staff did not offer to wash his hands before serving him the meal. During further interview Resident #49 stated he would wash his hands before eating a lunch meal at home. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Diabetes, and Heart Failure. Review of the comprehensive care plan for Resident #140 revised on [DATE], revealed .resident has ADL self-care performance deficit . Review of an admission MDS assessment dated [DATE], revealed Resident #140 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required moderate assistance for personal hygiene. During an observation on [DATE] at 12:07 PM, CNA G delivered the lunch meal tray to Resident #140. CNA G set up the meal tray and exited the room without offering hand hygiene assistance to the resident. During an interview on [DATE] at 12:10 PM, CNA G stated .we don't usual offer to wash the residents' hands who eat in their rooms .we only offer hand hygiene to the residents who eat in the dinning room .we probably should offer hand hygiene to all residents before all meal . During further interview CNA G confirmed hand hygiene was not offerred to Residents #59, #49, and #140 before the lunch meal. During an interview on [DATE] at 3:37 PM, the IP stated staff were to offer hand hygiene to all residents before serving a meal and before assisting a resident with a meal. During further interview the IP confirmed CNA G failed to maintain infection prevention practices during a mealtime for Residents #59, #49, and #140. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Colostomy, Anxiety, Lack of Coordination, and Major Depressive Disorder. Review of the comprehensive care plan for Resident #30 dated [DATE], revealed .Enhanced Barrier Precaution r/t Ostomy .EBP- wear gown and gloves during adl care, incontinent care, foley care, transfers, wound care, and any provision of care with an increased risk for MDRO [Multi-Drug Resistant Organisms] . Review of a physician's order for Resident #30 dated [DATE], revealed .Clean left heel with wound cleanser, apply foam dressing change every 5 days and PRN [as needed] . Continued review revealed .Clean right lateral ankle with wound cleanser apply foam dressing to area change every 5 days and PRN . Review of a physician's order for Resident #30 dated [DATE], revealed .Enhanced Barrier Precautions .every shift . During an observation on [DATE] at 8:10 AM, the Assistant Director of Nursing (ADON) and CNA B were in Resident #30's room changing the resident. The ADON and CNA B wore gloves during the patient care interaction and no gown. During an interview on [DATE] at 8:38 AM, the ADON stated she and CNA B were changing Resident #30's brief and checking her colostomy. The ADON confirmed they wore gloves while changing the resident and had not worn a gown during the resident care interaction. The ADON confirmed Resident #30 was on EBP because of her colostomy and wounds and required a gown and gloves for all direct care including changing the resident. The ADON stated staff know which residents are on EBP from the kardex (care instructions for direct care staff) located in the residents' room behind the closet door. The ADON was unaware how outside care providers (hospice, radiology, lab) and families would know that residents were in EBP and required a gown and gloves for direct patient care activities. During an observation and interview on [DATE] at 8:43 AM, in Resident #30's room, with the ADON, there was a document taped to the back of the resident's closet that read .EBP-wear gown and gloves during adl care, incontinent care, foley care, transfers, wound care . During an interview on [DATE] at 8:46 AM, CNA B stated she assisted the ADON to change Resident #30. CNA B confirmed Resident #30 was on EBP and she only wore gloves to change the resident. CNA B confirmed she should have worn a gown as well to change Resident #30. This surveyor asked the CNA how she knew which residents required EBP and the CNA stated .we just know which ones have catheters, feeding tubes, and things that are not naturally in the body . During an interview on [DATE] at 12:27 PM, the DON confirmed Resident #30 was on EBP because the resident had wounds and a colostomy. The DON stated a gown and gloves were required for direct care activities for residents on EBP. Direct care activities included .changing briefs .linens .bathing . The DON stated staff know what residents require enhanced barrier precautions from the kardex taped on the back of the residents' closet door. The DON stated residents' families were notified of EBP via (by way of) phone or in care plan meetings and was unaware how outside care providers (hospice, radiology, lab, dental, podiatry) would know if a resident required EBP. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Brain Damage, Feeding Difficulties, Lack of Coordination, and Skin Infection. Review of the comprehensive care plan for Resident #27 dated [DATE], revealed .Enhanced Barrier Precautions .wear gown and gloves during adl care, incontinent care, foley care, transfers, wound care, or any provision of care with increased risk for MDRO . Further review of the comprehensive care plan revealed the resident received dressing changes for skin impairment. Review of a Physician's order for Resident #27 dated [DATE], revealed .Enhanced Barrier Precautions .every shift . Review of a Physician's order for Resident #27 dated [DATE], revealed .Clean ulcer to underside of 4th toe right foot with wound cleanser, apply [name brand medication] to ulcer and cover . Review of a quarterly MDS assessment dated [DATE], revealed Resident #27 scored an 8 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required maximal staff assistance for bed mobility. During an observation on [DATE] at 10:04 AM, CNA F was observed standing beside Resident #27's bed while the resident was in the bed and was not wearing a gown. Further observation revealed dirty linen was placed in the floor, CNA F picked the dirty linen up off the floor, held them against her body, and then placed the soiled linen on the resident's countertop. CNA F placed the soiled linen from the countertop and placed it into a bag, then placed the linen in a soiled linen receptical. During an observation and interview on [DATE] at 10:20 AM, CNA F stated she changed soiled bed linens with Resident #27 in the bed. CNA F stated the resident was not on Enhanced Barrier Precautions and did not require a gown for personal care and stated residents who required Enhanced [NAME] Precautions would have a Kardex in their closet which notified the staff of the requirement. CNA F confirmed she placed soiled linen in the floor and held them against her body and then placed them on the resident's countertop. The CNA confirmed she failed to maintain infection control practices when providing personal care to Resident #27. During an observation CNA F confirmed the Kardex in Resident #27's closet included Enhanced Barrier Precautions. During an interview on [DATE] at 3:37 PM, the IP stated soiled linen should be placed directly into a bag and not into the floor. The IP also stated staff were expected to wear a gown when making an occupied bed for residents on Enhanced Barrier Precautions. The IP confirmed CNA F failed to maintain infection control practices. 50480 Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Heart Disease. Review of a quarterly MDS assessmenReview of the facility's policy titled, Medication Administration, dated ,d+[DATE], revealed .wash hands prior to administering medication .identify expiration date .if expired notify nurse manager .administer medication as ordered in accordance with manufacturer specifications .wash hands . Review of the facility's policy titled, Hand Hygiene, dated ,d+[DATE], revealed .all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .hand hygiene table .condition .before and after eating .before preparing or handling medications . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Heart Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required assistance with ADL care. Review of the comprehensive care plan for Resident #13 revised [DATE], revealed the resident had a self-care deficit and required staff assistance with activities of daily living and care. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Need for Assistance with Personal Care, and Muscle Weakness. Review of a quarterly MDS dated [DATE], revealed Resident #73 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required assistance with ADL care. Review of the comprehensive care plan for Resident #73 revised [DATE], revealed the resident had a self-care deficit and required staff assistance with activities of daily living and care. During an observation on [DATE] at 8:00 AM, in Resident #13's room, revealed the IP gave Resident #13 a drink of water and touched the bed remote. The IP exited Resident #13's room, did not perform hand hygiene, went out into the hallway to the medication cart to start preparing Resident #73's medication for administration. The IP touched the medication cart keys located in her pocket, touched multiple medication drawers, and touched multiple medication packages. The IP went into Resident #73's room, administered medications to Resident #73, and failed to perform hand hygiene before or after administering the medications to Resident #73. The IP exited Resident #73's room and did not perform hand hygiene upon exit. During an interview on [DATE] at 8:18 AM, the IP stated hand hygiene should be completed before and after direct contact with the resident or resident surfaces. The IP confirmed she failed to complete hand hygiene after exiting Resident #13's room and before and after administering medications to Resident #73. During an interview on [DATE] at 8:44 AM, the DON confirmed hand hygiene should be completed before and after contact with the resident and resident surfaces. 48100

Based on facility policy review, record review, and interview, the facility failed to implement transmission-based precautions when Resident #5 was not moved to a single-person room following a positive Coronavirus (COVID-19) test result. This affected 1 resident (Resident #4) with the potential to result in COVID-19 transmission. Findings include: Review of the undated facility policy titled, Coronavirus Disease (COVID-19) Patient Placement Guidelines revealed .Resident suspected of having COVID-19 or confirmed of having Covid-19 will be placed on the isolated Short Stay Hallway until further direction are given . Review of the undated facility policy titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes revealed .Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending .If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results .Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed Resident #5 was fully vaccinated. She received her first COVID-19 vaccine dose on 1/28/2021 and her second dose on 2/25/2021. The resident received her booster dose on 10/28/2021. Review of the COVID-19 Screening, dated 2/28/2022 at 8:55 AM, revealed Resident #5's COVID-19 Ag Card Result was positive. Review of Nursing Progress Note, dated 2/28/2022 at 10:33 AM, revealed .On Monday, February 28th resident as swabbed along with all the other residents. Her antigen test was positive. She did not exhibit any symptoms. She had no fever, no cough, no congestion. As per our protocol, we did a [polymerase chain reaction] PCR and sent to lab . Resident #5 resided in the same room as Resident #4, when Resident #5 tested positive for COVID-19 on 2/28/2022. Resident #4 was fully vaccinated for COVID-19 and did not subsequently contract COVID-19 following the potential exposure. Review of Laboratory Test, dated 3/1/2022 at 5:42 AM, revealed Severe Acute Respiratory [CONDITION(S)]-CoV-2 RNA was detected on the PCR test; the resident was positive for COVID-19. Review of Nursing Progress Note, dated 3/1/2022 at 5:02 PM, revealed .Resident moved to room [ROOM NUMBER] A, tolerating room change well, remains on contact/droplet precautions for positive COVID-19 . During interview conducted on 3/9/2022 at 3:28 PM, Licensed Practical Nurse (LPN)/Infection Control Nurse, stated Resident #5 first tested positive for COVID-19 on 2/28/2022 following a rapid antigen test. A PCR test was then obtained per facility protocol. The PCR test result was positive for COVID-19 and was received on 3/1/2022. Resident #5 was not transferred to a private room nor the COVID-19 hallway until 3/1/2022. Resident #5 was placed on contact/droplet precautions on 2/28/2022, however, she continued to reside with her roommate, Resident #4, until 3/1/2022. During interview conducted on 3/10/2022 at 2:09 PM, the Administrator confirmed Resident #5 should have been moved to the COVID-19 hallway, on 2/28/2022, following the positive COVID-19 rapid antigen test.

Based on facility policy review, medical record review, review of facility investigation, and interviews, the facility failed to ensure a resident was safely and correctly transferred, causing a fall with a transverse fracture of the distal fibular metaphysis and bilateral non-displaced tibial fractures (age indeterminate), resulting in harm to Resident #1. The harm affected 1 of 3 residents (Resident #1) reviewed for falls. Findings include: Review of the facility policy titled, Fall Prevention Program, dated 2/5/2021, revealed .Patients will be cared for in a safe environment. Fall prevention procedures are based on the assessment of the patient, determination of the patient's risk for fall and implementation of interventions that reduce the intrinsic and extrinsic fall risks identified .assisted fall is a fall in which any staff member was with patient and attempted to minimize the impact of the fall by slowing the patient's descent. Example: a patient who is ambulating becomes weak and the staff lowers the patient to the floor. This is considered a fall because the patient did not intend to go to the floor; it is an assisted fall because the staff eased the patient's descent to reduce the likelihood of injury . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Delusional Disorders, Anxiety Disorder, Abnormal Weight Loss, History of Coronavirus (COVID-19), Muscle Weakness, and [CONDITION(S)] ([CONDITION(S)]). Medical record review of the Minimum Data Set (MDS) assessment, dated 5/17/2021, revealed Resident #1 scored a 3 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Continued review revealed no [CONDITION(S)], behaviors, or rejection of care. The resident required extensive, two-person assistance for bed mobility, and was totally dependent requiring two-person assistance with transfers and toileting. There were no falls since admission or prior assessment. Review of the Care Plan, dated 5/1/2017, revealed the resident has an Activities of Daily Living (ADLs) self-care performance deficit related to dementia and fatigue with interventions including the resident is dependent upon 2 staff for toilet use, the resident requires a mechanical lift (Hoyer) with the assistance of 2 staff for transfers, and to encourage the resident to participate, to the fullest extent possible, with each interaction. Review of the Fall Risk Assessment, dated 1/10/2021, revealed the score of 10, indicating a high risk for falls. Review of the Self-Reported Incident (SRI) revealed .Incident #: 026 .It was reported to administrator this date that resident was complaining of pain to bilateral ankles and presented with bruising to bilateral ankles. Nurse Practitioner (NP) ordered x-rays. Results showed bilateral nondisplaced tibial fractures, age indeterminate for both; and a nondisplaced fracture of the right fibular head . Review of a NP Progress Note, dated 7/9/2021, revealed .no recent falls reported .small bruising to legs .Addendum: Nursing reported some bruising and pain to her bilateral lower extremity (BLE) on 7/9/2021. No injury was reported at that time to me. Patient stated her legs hurt and ached. She tested positive for Flu B . Review of a NP Progress Note, dated 7/13/2021, revealed .patient is a [AGE] year-old female being seen today to follow-up with x-rays. Nursing called me early this morning reporting that her legs were hurting worse and she was having bruising to her ankles and right knee. I ordered for them to get x-rays on bilateral ankles and right knee . Review of a NP Progress Note, dated 7/14/2021, revealed .nurses requesting I schedule [MEDICATION(S)] .she is in pain .BLE leg pain due to fractures .[MEDICATION(S)] helped this morning when nursing gave it .no recent falls reported but patient has some fractures .bruised to BLE, ankles and right knee .nondisplaced fracture of right fibula .findings suspicious for bilateral tibial fractures . Review of a Radiology Report, dated 7/13/2021 revealed .two views of both ankles were obtained .impression: findings suspicious for bilateral nondisplaced tibial fractures .these may reflect nondisplaced fractures of undetermined age . Review of a CT Scan, obtained on 7/14/2021, revealed .routine non-contrast CT of the right lower extremity obtained .Impression: minimally displaced fractures of both proximal and distal aspects of the fibula. There is a transverse fracture of the distal fibular metaphysis. Severe diffuse [CONDITION(S)]. Hemarthrosis of both ankle and knee. Review of a CT Scan, obtained on 7/14/2021, revealed 2 views of both ankles were obtained .there are areas of cortical irregularity in the anterior and medial right tibia. These may reflect nondisplaced fractures of undetermined age .findings suspicious for bilateral nondisplaced tibial fractures . Review of a Nursing Progress Note, dated 7/13/2021 at 6:48 AM, revealed .this nurse was called to resident's room by wound care nurse stating she has bruising but she always has some due to poor skin but she is complaining of pain when I touch her. This nurse, wound care nurse, and MDS nurse went to room resident noted to have bruising to bilateral ankles, right knee, with small round scattered bruising noted to lower right extremity .right foot noted to be turned in toward left foot .notified NP received orders to x-ray bilateral ankles and right knee . Review of the Incident Investigation Tracker, dated 7/13/2021, revealed the root cause analysis determined the cause of the witnessed fall was the CNAs did not know the resident was care planned for a Hoyer Lift and the care task was not specify Hoyer Lift on the plan of care. Review of the Medication Administration Record (MAR), dated July 2021, revealed the order for non-weight bearing to BLE's. Take extra care with bilateral ankles and right knee when turning in bed. Further review of the MAR revealed the order for [MEDICATION(S)] tablet 50 milligrams (mg), give one tablet two times a day for moderate to severe pain related to unspecified fracture of shaft of unspecified tibia, initial encounter for closed fracture. The resident received the [MEDICATION(S)] 7/14/2021 through 7/19/2021. Further review of the MAR revealed the order for [MEDICATION(S)] 5-325 mg, one tablet by mouth every 6 hours as needed for pain related to unspecified fracture of shaft of unspecified tibia, initial encounter for closed fracture. The resident received the [MEDICATION(S)] on 7/22/2021 through 7/27/2021, and 7/30/2021 through 7/31/2021. During interview conducted on 8/3/2021 at 10:16 AM, Certified Nursing Assistant (CNA) #1 confirmed Resident #1 was not transferred with a mechanical lift per her plan of care. CNA #1 stated, We were getting her up to transfer her to the shower chair. We eased her down to the floor and two more came in and we lifted her into the shower chair. We always transferred her with two people. We had her on the edge of the bed and we lifted and she went down and we eased her to the floor. I don't think she was able to ever bear any weight. The shower girls came and got her and we went out. I didn't consider it a fall. We told her nurse right away. During interview conducted on 7/8/2021 at 2:33 PM, the Administrator confirmed Resident #1 was improperly transferred without the use of a mechanical lift as ordered, which resulted in a fall. The Administrator confirmed the staff did not report the fall timely, as there was miscommunication among the nursing staff. The Administrator stated it came to his attention on 7/13/2021 of Resident #1's knee and ankle fractures and an investigation was initiated which revealed there had been an unreported fall on 7/8/2021.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain a sanitary environment for 3 of 5 sample residents (Resident #23, #28, and #48) who required enteral tube feeding. The findings include: Review of the facility's policy, titled, Daily Occupied Patient Room Cleaning, dated 12/9/2020, revealed, .Disinfect and spot clean: Using a Hospital Approved Disinfectant and a clean cloth, clean all spots and hand contact areas working clockwise around the room. Include overbed tables, bedside table, telephone, chairs, ledges light switches, spots on walls, outside surface of wall-mounted sharps containers, and IV [Intravenous] poles and linen hampers . Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Specified Intracranial Injury, History of Traumatic Brain Injury, Attention to Gastrostomy, and Dysphagia, Oropharyngeal Phase. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 required a feeding tube. Review of the Physician's Order Summary Report dated June 28, 2021, revealed, Resident #23 had a physician's order dated 3/15/2021, .[MEDICATION(S)] 1.5 Cal [Calorie] Liquid (Nutritional Supplements) Give 50 cc [cubic centimeters] via G-Tube [Gastrostomy] every shift for nutritional [MEDICATION(S)] 1.5 cc/hr [hour] for 20 hours, off 6am & 6pm, on 8am & 8pm . Observations in the resident's room on 6/28/2021 at 10:35 AM, 11:39 AM, 3:21 PM, and 3:53 PM, revealed Resident #23's enteral feeding pump, pole and the base of the pole had a moderate amount of dried tan debris. Observation and interview in the resident's room on 6/28/2021 at 4:05 PM, Registered Nurse (RN) #1 confirmed Resident #23's enteral feeding pump, pole and base of pole had a moderate amount of dried tan debris. She stated, I think it's dirty. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses which included Attention to Gastrostomy, Dysphagia, Oropharyngeal Phase. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #28 required a feeding tube. Review of the Physician's Order Summary Report dated June 28, 2021, revealed, Resident #28 had a physician's order dated 10/15/2020, .Glucerna 1.5 Cal Liquid (Nutritional Supplements), Give 40 ml/hr [milliliters/hour] via G-Tube every shift for to provide 920ml and 1380 cal per day . Observations in the resident's room on 6/28/2021 at 10:52 AM, 11:38 AM, 12:29 PM, 3:16 PM and 3:51 PM, revealed Resident #28's enteral feeding pump, pole and base of pole had a moderate amount of dried tan debris. Observation and interview in the resident's room on 6/28/2021 at 4:00 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #28's tube feeding pump, pole and base of pole had a moderate amount of dried tan debris. Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses which included, Encounter for Attention to Gastrostomy, Hypertension, and [CONDITION(S)] Brain. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #48 required a feeding tube. Review of the Physician's Order Summary Report dated June 28, 2021, revealed, Resident #48 had a physician's order dated 6/18/2021, .[MEDICATION(S)] 1.5 Cal [Calorie] (Nutritional Supplements) liquid; give 55 ml, via G-Tube 23 hours a day related to encounter for attention to Gastrostomy . Observations in the resident's room on 6/28/2021 at 10:24 AM, 1:30 PM, and 3:10 PM, revealed Resident #48's enteral feeding pump base had a moderate amount of dried tan debris. Observation and interview in the resident's room on 6/28/2021 at 3:10 PM, LPN #1 and LPN #2 confirmed the enteral feeding pole base had a moderate amount of dried tan debris. During an interview on 6/29/2021 at 10:20 AM, the Director of Nursing (DON) stated the nursing staff were to clean the enteral feeding pumps and poles with any spills and when visibly soiled.

Based on facility policy review, medical record review, observation, and interview, the facility failed to change and date oxygen tubing and humidified water bottle for 1 of 8 sample residents (Resident #63) receiving respiratory therapy. The findings include: Review of the facility policy titled, Oxygen Therapy, dated 11/14/2019, revealed, .all oxygen tubing and masks, etc. should be changed out weekly and/or prn [as needed] and labeled with the date of the last change . Review of the medical record, revealed Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed the resident had signs and symptoms of [CONDITION(S)] with altered level of consciousness and the resident had not received Oxygen therapy in the assessment reference period. Review of the Order Summary Report dated from 11/22/2019 to present, revealed no order for weekly oxygen equipment changes for Resident #63. Observation in the resident's room on 6/29/2021 at 8:04 AM, revealed Resident #63 was in bed with oxygen being administered per nasal cannula at 2 ½ liters per minute. Continued observation revealed the oxygen tubing was not dated and the humidified water bottle was dated 6/21/2021. Observation and interview in Resident #63's room on 6/29/2021 at 8:35 AM, Licensed Practical Nurse (LPN) #2 confirmed the resident's oxygen tubing was not dated and the humidified water bottle was dated 6/21/2021. LPN #2 stated the oxygen tubing and humidified water bottle should be changed and dated on Sunday nights and PRN. Observation and interview in Resident #63's room on 6/29/2021 at 9:03 AM, the Director of Nursing (DON) confirmed the resident's oxygen tubing was not dated and the humidified water bottle was dated 6/21/2021. She stated the oxygen tubing and humidified water bottle should have been changed on Sunday (June 27).

Based on facility policy review, medical record review, and interview, the facility failed to coordinate the timely completion of a Level II Pre-Admission Screening and Resident Review (PASARR) for 1 of 4 sample residents (Resident #80) reviewed. The findings include: Review of the facility policy titled, Pre-Admission Screening and Annual Resident Review (PASARR), dated 5/24/2019, revealed, .Notification to state mental authority for resident review will occur promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability . Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with readmission on 11/20/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue review revealed additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) for Resident #80 dated 5/21/2021, revealed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/29/2021 at 5:40 PM, the Social Service Director confirmed Resident #80 did not have a Level II PASARR and had a Mental Illness diagnosis.

Based on facility policy review, medical record review, and interview the facility failed to revise comprehensive care plans for 1 of 38 sample residents (Resident #63) reviewed. Review of the facility's policy titled, Care Plan, dated 9/23/2020, revealed, .The plan should be kept current and flexible to meet the resident's changing problems or needs . Review of the medical record, revealed Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed the resident was assessed to require one-person extensive assistance. Review of the medical record, revealed a Registered Dietician note dated 5/17/2021, stated Resident #63 required staff to feed her. Review of the Tennessee Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Care Plan dated 5/17/2021, revealed a plan of care developed to address Antidepressant medication related to Depression. Continued review of the Antidepressant Care Plan dated 5/17/2021, revealed intervention to educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of [MEDICATION(S)] (a medication to treat depression) which was discontinued on 8/5/2019. Review of the Comprehensive Care Plan dated 5/11/2020, revealed a plan of care developed for Resident #63 to address an Activities of Daily Living (ADL) intervention for eating with the resident able to feed herself after tray set up. Continued review of the Care Plan dated 5/11/2020, revealed a plan of care developed to address Resident #63's nutritional problem to assist with tray set up and dining PRN (as needed). Continued review revealed the resident's care plan was not revised to reflect the resident's current decline requiring feeding assistance. Review of the Care Plan for Resident #63 on 6/30/2021, revealed no revisions to reflect the resident's comfort care status. During an interview on 6/30/2021 at 3:44 PM, Registered Nurse (RN) #2 confirmed she is responsible for updating the resident's care plans. RN #2 reviewed Resident #63 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, I should have updated the care plans and I didn't. During an interview on 6/30/2021 at 4:44 PM, the Director of Nursing reviewed Resident #63's physician orders, MDS, and care plan. She confirmed the resident's care plan had not been updated.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure 1 of 38 sample residents (Resident #56) had clean and groomed fingernails. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADL's), reviewed 11/14/2019, revealed .All residents will receive necessary assistance to carry out ADL's to maintain good nutrition, grooming and personal and oral hygiene. To meet the resident's personal hygiene and activities of daily living needs. These needs will be met but are not limited to the following: Nail care . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Continued review revealed Resident #56 required extensive assistance of staff for personal hygiene. Observation in the resident's room on 6/28/2021 at 3:44 PM, revealed Resident #56's fingernails on her right hand had dark debris under them. Observation and interview in the resident's room on 6/29/2021 at 10:55 AM, with Certified Nurse Aide (CNA) #1 revealed Resident #56's fingernails on her right hand had dark debris under them. Continued interview confirmed Resident #56's fingernails were not clean. Observation and interview in the resident's room on 6/29/2021 at 11:07 AM, with Licensed Practical Nurse (LPN) #3 confirmed Resident #56's fingernails were dirty.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection for 1 of 6 sample residents (Resident #7) who required an indwelling urinary catheter. The findings include: Review of the facility's policy, titled, Foley Catheter Insertion, Care, and Infection Prevention Guidelines,dated 6/5/2020, revealed, .[Named facility] follows an evidence-based approach to urinary tract catheter use, insertion and maintenance to decrease the incidence of infection related to urinary catheter insertion and maintenance .12. Maintenance of the urinary Catheter .c. Drainage bag should not touch the floor . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 required an indwelling urinary catheter. Observations in the resident's room on 6/28/2021 at 3:17 PM and 3:52 PM, revealed Resident #7's urinary catheter drainage bag was on the floor. Observation and interview in the resident's room on 6/28/2021 at 4:02 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #7's urinary drainage bag was on the floor.

Based on medical record review and interview, the facility failed to accurately assess weights on the Quarterly Minimum Data Set (MDS) assessment for 1 of 38 sample residents (Resident #62) reviewed. The findings include: Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #62 had a weight loss of 5% in a month or 10% in 6 months. Review of the Weights and Vital Summary Report dated June 2021, revealed Resident #62 did not have weight loss from November 2020 to June 2021. During an interview on 6/30/2021 at 8:35 AM, the MDS Coordinator confirmed he made a mistake when inputting the weight loss data for Resident #62. During an interview on 6/30/2021 at 8:35 AM, the Director of Nursing stated the Quarterly MDS for Resident #62 did not contain the correct information related to weights.

Based on facility policy review, observation, and interview, the facility failed to keep a clean and sanitary privacy curtain for 1 of 78 rooms (Room 84) observed. The findings include: Review of the facility's policy titled, .Privacy Curtain Cleaning, reviewed 12/9/2020, revealed .Privacy curtains should be checked daily for spots, spills, and general soiling and are to be laundered (or dry-cleaned if necessary) annually or as needed. To prevent cross-contamination, privacy curtains should be changed after isolations or any time soiling is detected . Observation of Room 84 on 6/28/2021 at 3:32 PM, revealed the privacy curtain had brown raised specks on the bottom of the curtain. Observation of Room 84 on 6/29/2021 at 8:29 AM, revealed the privacy curtain had brown raised specks on the bottom of the curtain. Observation and interview of Room 84 on 6/30/2021 at 3:02 PM with the Environmental Service Manager confirmed that the privacy curtain had a brown raised specks on the bottom of the curtain. Continued interview she stated the curtain was dirty and it should be checked every day when the room was cleaned.

Based on review of the Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, policy review, medical record review, hospital record review, observation, and interview, the facility failed to ensure residents received the correct medications as ordered by the physician for 2 of 9 sampled residents (Resident #1 and #2) reviewed for significant medication errors. The failure of the facility to ensure medications were administered to the correct residents resulted in actual Harm for Resident #1 when the resident was administered another resident's medications and was transported to the emergency room with lethargy and abnormal vital signs. Resident #1 was admitted to the Intensive Care Unit to be monitored closely. The findings include: Review of the Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, page 1261, showed, .When a physician or other health care professional writes a medication order, it includes specific directives for the pharmacist filling the order, for the person taking the medications, and for the nurse administering the medication. Information includes the (1) name of the person to receive the medication (2) date and time .(3) name of the medication to be administered (4) dosage (5) route of administration . Review of the facility's policy titled, Medication Administration, dated 8/8/2019, showed, .PURPOSE: To establish guidelines to maintain a high level of safety and accuracy in the administration of medications .medications should be administered by the 5 rights .Patients are addressed by name and are verified with photograph .in electronic health record . Medical record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed the resident had moderate hearing loss and she was cognitively intact for decision making. Review of the July 2020 physician's orders [REDACTED].#1's bedtime medications were [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligram (mg) (given for Anxiety), [MEDICATION NAME] tablet 20 mg (medication for High Cholesterol), carvedilol tablet 3.125 mg (medication for [MEDICAL CONDITION], MI and Hypertensive [MEDICAL CONDITION]), tamsulosin 0.4 mg (medication to improve urine flow rate) and [MEDICATION NAME] tablet 200 mg every 4 hours as needed for pain (over-the-counter pain reliever). The resident took her medications by mouth. Review of the facility's Medication Error Report dated 7/23/2020, showed, .Patient (Resident #1) was in the computer in (named room A bed) .instead of (named room B bed) .I gave her the wrong meds (medications) at 2313 (11:13 PM) on 7/22/2020. I discovered the error at about 4:30 AM on 7/23/2020 when I went to get her a thickened water. The CNA (Certified Nursing Assistant) told me she was not on thickened liquids . Registered Nurse (RN) #1 documented she notified the physician in this Medication Error Report. Vital signs and further assessment of Resident #1's status were not documented in the Medication Error Report or the Nurses' Notes. There was no documentation the physician was notified in the Nurses' Notes. The next vital signs and assessment were documented by RN #2, the nurse working 7/23/2020 on the 6:00 AM - 6:00 PM shift. Review of the Nurses' Notes written by RN #2, dated 7/23/2020 at 9:00 AM, showed, .After receiving shift report Spoke (spoke) to (Resident #1's Responsible Party (RP)) on phone. (RP) concerned because (Resident #1) was not answering the phone. This nurse had just checked on patient (Resident #1) who was very groggy, however did mumble something when this nurse spoke to her and touched her on the arm. Patient's VS (vital signs) are BP (blood pressure) 97/58, P (pulse) 50, RR (respiratory rate) 16, Temp (temperature) 97, O2 (oxygen saturation) 98% on 2L (2 liters) BNC (binasal cannula oxygen) at 0730 (7:30 AM). Rechecked BP 109/54, P 55 at 0840 (8:40 AM) . Review of the Nurses' Notes written by RN #2 dated 7/23/2020 at 10:00 AM, showed, .Change in status from beginning of this shift. Patient (Resident #1) not responding to tactile stimuli. Doctor notified by (Named RN #1). Order to send to ER (emergency room ). Family notified by (Named RN #1) . Review of the hospital Physician's Admission History and Physical (H&P) dated 7/23/2020, showed, .(Resident #1) well known to me from recent admission this month ([DIAGNOSES REDACTED].In the emergency room she (Resident #1) was minimally responsive to sternal rub .ASSESSMENT AND PLAN: 1. toxic [MEDICAL CONDITIONS] secondary to accidental ingestion of her roommate's medications which included [MEDICATION NAME] 0.5 milligrams (Resident #1 was already prescribed this medication), [MEDICATION NAME] (cardevilol) 25 milligrams which is considerably higher than her dose of 13.125, [MEDICATION NAME] 600 milligrams which she does not normally take, [MEDICATION NAME] 10 milligrams that she does not normally take, [MEDICATION NAME] 50 milligrams which is not one of her medications, and [MEDICATION NAME] 100 milligrams which is not a current medication .She is minimally responsive however is protecting her airway. She will be placed in ICU (Intensive Care Unit) and monitored closely. Neuro (neurological) checks will be performed. Medications will be held until she is taking p.o. (by mouth) any sedated medications will be stopped. 1. Carvedilol will be held. 2. [MEDICAL CONDITION] with a rate down to 34 with a dose of 25 milligrams of carvedilol as opposed to 3.125 she normally takes. Will monitor closely for any episodes at the time of my exam her heart rate was in the 40s (normal heart rate for an adult is between 60 and 100 beats per minute) . The following medications that were listed in the H & P could potentially cause a significant change in Resident #1's health status: a. [MEDICATION NAME] 600 mg (prescribed to Resident #2 for [MEDICAL CONDITION] which is nerve pain - potential side effects of breathing problems, dizziness and drowsiness.) b. cardevilol 25 mg (prescribed to Resident #2, Resident #1 had a lower prescribed dose of 3.125 mg and was prescribed for Hypertensive [MEDICAL CONDITION] and status [REDACTED].) c. [MEDICATION NAME] 50 mg (an antipsychotic prescribed to Resident #2 for [MEDICAL CONDITION] with Behavior Disturbance, Verbal Aggression, Disruptive and Repetitive Behaviors, Severe Restlessness - potential side effects of confusion, changes in mood, fast and uneven pulse, trouble controlling body movements, flu-like symptoms, severe dizziness, trouble passing urine.) d. [MEDICATION NAME] 100 mg (opioid-like pain medication prescribed to Resident #2 for moderate to severe pain - potential side effects of confusion, chest pain or pressure, difficulty with urination.) Review of the hospital Physician's Progress Note dated 7/24/2020 at 2:30 PM, showed significant improvement in Resident #1's condition. Her BP was 84/65 at 8:10 AM, O2 saturation was 97%, pulse was 69, RR was 27, and Temp was 98.3. She had intermittent episodes of uncontrollable shaking and cold sensation. Blood cultures were collected and she was started on intravenous antibiotics as a precautionary measure due to the absence of a Spleen. Due to [MEDICAL CONDITION], an indwelling urinary catheter was placed. The hospital Discharge Summary dated 7/25/2020, showed, the discharge [DIAGNOSES REDACTED].) Resident #1 was transferred back to the facility. Observation and interview in the resident's room on 7/29/2020 at 2:30 PM, showed Resident #1 was alert and oriented, lying in bed working in a word search puzzle book. When asked about her recent hospital stay, the resident stated that she had received the wrong medications. She had taken the medications that were given to her but otherwise didn't recall the circumstances. Medical record review for Resident #2 showed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #2 was cognitively intact for decision making, and required supervision with transfer. Review of the Comprehensive Care Plan updated 5/28/2020, showed Resident #2 was at risk of falling with a history of noncompliance, decreased safety awareness and repeated falls. Review of the July 2020 physician's orders [REDACTED].#2's bedtime medications were [MEDICATION NAME] tablet 10 mg (hormone to assist with sleep), [MEDICATION NAME] (carvedilol) tablet 25 mg, [MEDICATION NAME] tablet 600 mg, [MEDICATION NAME] tablet 0.5 mg, [MEDICATION NAME] 50 mg (ordered 7/18/2020) and [MEDICATION NAME] 100 mg (ordered 7/22/2020). Review of the Nurses' Note dated 7/23/2020 at 9:35 AM (late entry), showed that RN #2 heard a noise from down the hall and she and the CNA entered Resident #2's room. The resident was sitting in the floor with her back against her bed next to the bedside commode. Her BP was 120/61, her heart rate was 75, her respiratory rate was 19, and her oxygen saturation was 92%. Neurological checks were initiated. Upon assessment there was no injury noted. Resident #2 was transported to the hospital for evaluation. The Nurses' Note dated 7/23/2020 at 12:15 PM, showed that Resident #2 returned to the facility with a [DIAGNOSES REDACTED].>Review of the hospital records dated 7/23/2020, showed Resident #2 was transported to the hospital by Emergency Medical Services (EMS) and arrived at 8:40 AM. EMS informed the hospital that the resident had fallen at the facility during the morning hours of 7/23/2020 while attempting to transfer herself from bed to the bedside commode. Neurological checks had been initiated and were within normal limits. EMS also reported that she had received the wrong medications on night shift on 7/22/2020. These medications included: a. [MEDICATION NAME] 0.5 mg (prescribed to Resident #1, Resident #2 was prescribed this same dose also) b. carvedilol 3.125 mg (prescribed to Resident #1, Resident #2's usual ordered dose was 25 mg at bedtime) c. [MEDICATION NAME] 20 mg (prescribed to Resident #1, a medication for high cholesterol - potential side effects of headache and dizziness) d. [MEDICATION NAME] 200 mg (prescribed to Resident #1 and is an over the counter pain reliever) e. tamsulosin 0.4 mg (prescribed to Resident #1,a medication to improve urine flow rate - potential side effects of low BP and dizziness) Resident #2's BP was 133/55, her heart rate was 76, the RR was 18, her Temp was 98.1, and her O2 saturation was 100% on 5 liters BNC (Resident #2 was on continuous O2 at the facility). Resident #2's ER discharge [DIAGNOSES REDACTED]. She was not noted to have complications related to receiving Resident #1's bedtime medications or deficits noted. Observation in the resident's room on 7/29/2020, showed Resident #2 was in COVID-19 isolation for 14 days due to a recent hospital visit. Personal protective equipment was available on the door of the room and isolation signage was present. The resident was observed from the hallway. Her eyes were closed and she was resting quietly. During an interview on 7/31/2020 at 3:55 PM, the Director of Nursing (DON) confirmed RN #1 had given Resident #1 her roommate's (Resident #2's) bedtime medications and Resident #2 had been administered Resident #1's medications on the 6:00 PM-6:00 AM shift on 7/22/2020. During a telephone interview on 7/31/2020 at 7:15 PM, Resident #1's Responsible Party (RP) and Power of Attorney for both finances and care, was asked about Resident #1 receiving the wrong medications on 7/22/2020. She stated that Resident #1 had told her that the nurse came in and plopped down the medication and left the room. During an interview on 7/31/2020 at 7:40 PM, RN #2 stated that she and RN #1 had gotten a late start on change of shift report due to being interrupted with patient care. She had checked on Resident #1 at about 8:30 AM on 7/23/2020. The resident had moaned and moved her hand. RN #2 stated that she had not known about the medication error at that time. When the change of shift report was completed, and she had been made aware of the error, she went back to assess Resident #1 more thoroughly. Resident #1's heart rate had been 41 beats per minute. RN #1 was notifying the residents' families of the medication error. During the phone call Resident #1's RP had requested that the resident be sent to the hospital for evaluation. The physician was notified and an order was received to transfer Resident #1 to the ER for further evaluation. During a telephone interview on 8/1/2020 at 2:30 PM, the facility's Medical Director stated that he had been informed of the medication error. He and RN #1 had discussed the residents' conditions, medications, who got what medications and he hadn't anticipated the deterioration in Resident #1's condition. He confirmed RN #1 was told to monitor both of these residents. The failure of the facility to ensure medications were administered to the correct residents resulted in actual Harm for Resident #1 when the resident was administered another resident's medications and had to be transported to the emergency room with lethargy and abnormal vital signs, and was admitted to the Intensive Care Unit to be monitored closely.

Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 15 sampled residents (Resident #1 and #7) reviewed with wandering/exit seeking behaviors. Resident #1 and #7 were vulnerable residents with histories of wandering/exit seeking behaviors who eloped from the facility, which resulted in Immediate Jeopardy (IJ) for Resident #1 and #7. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and failed to supervise Resident #1 who was seen by a motorist at the edge of the facility property in the busy 4 lane state highway. Resident #1 was returned to the facility by the motorist that observed him in the highway. The facility failed to ensure a safe environment and failed to supervise Resident #7 who attempted to exit the building through a window in the Physical Therapy department on 4/7/2020, attempted to exit the building through a window in his room on 5/4/2020, and was seen by the Restorative Technician outside the facility in the facility parking lot unsupervised on 2/10/2020. This resulted in an IJ for Resident #1 and #7. The Administrator and the Interim Administrator were notified of the Immediate Jeopardy on 6/17/2020 at 4:12 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 2/10/2020 through 6/20/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 6/20/2020 at 3:00 PM, and was validated onsite by the surveyors on 6/21/2020 through policy review, observation, medical record review, review of education records, and staff interviews. The findings include: Review of the facility's policy titled, Elopement Risk/Wander Guard, revised date of 4/11/2019, showed, .Any resident with an altered mental status who has demonstrated behavior that puts them at risk for wandering/elopement will be considered an elopement risk . This policy did not contain a procedure for the assessment to determine if residents were at risk for elopement. Medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering Risk Scale assessment dated [DATE], showed that Resident #1 scored a 7, which indicated low risk for wandering and propelled himself up and down the hallway. Review of the quarterly Minimum Data Set (MDS) dated of 5/27/2020, showed Resident #1 had short and long term memory problems, and had some difficulty in cognitive skills for daily decision making. Resident #1's activities of daily living (ADLs) needs ranged from supervision to extensive assistance. He could not transfer independently and was not ambulatory. Review of a Plan of Care Note dated 6/4/2020, showed, .He (Resident #1) is alert with confusion . Review of the facility's video camera footage dated 6/6/2020 at 6:26 PM, showed Resident #1 was assisted by Licensed Practical Nurse (LPN) #1 out of the building through the front door entrance. The video footage revealed Resident #1 left the front porch at 6:33 PM. At 6:42 PM Resident #1 was returned to the facility by Certified Nursing Assistant (CNA) #1. Review of a Behavior Note dated 6/7/2020, showed, .On June 6, 2020 at approximately 1830-1850 (6:30 PM-6:50 PM), (Resident #1) went out the front door of the building. He was found in the parking lot area and brought back to the building . Review of a Psychiatric Evaluation dated 6/9/2020, showed, .Today on exam, he is only oriented to person; however, he was not fully cooperative with his exam .Judgement: Poor . Observation in the resident's room on 6/16/2020 at 10:55 AM, showed Resident #1 was alert and oriented, but had difficulty finding words to express himself. Resident #1 answered with I don't know to all questions and attempted to have conversation. Resident #1 had paralysis to the right side of his body. During an interview on 6/16/2020 at 12:02 PM, CNA #1 stated, .When we went outside to look we saw a gentleman and a woman with him (Resident #1). The man was pushing him (in a wheelchair) back up toward the front .The man said they had seen him in the highway . During a telephone interview conducted on 6/17/2020 at 1:32 PM, LPN #1 confirmed she had allowed Resident #1 to go outside the building unsupervised. LPN #1 stated, .It was my poor judgement in letting him out .He had been sitting on the front porch just that week. He had been out by himself then . The failure to supervise Resident #1 resulted in IJ. Medical record review showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering Risk Scale assessments for Resident #7 showed the following: a. The 12/28/2019 assessment showed a score of 7, which indicated the resident was at low risk for wandering, propelled himself up and down the hallway. b. The 2/10/2020 assessment showed a score of 9, which indicated the resident was at moderate risk for wandering and was found in the parking lot outside the facility. c. The 6/2/2020 assessment showed a score of 9, which indicated the resident was at moderate risk for wandering. d. The 6/17/2020 assessment showed a score of 11, which indicated the resident was at high risk for wandering. During an interview on 6/16/2020 at 1:50 PM, LPN #2 was asked what interventions were implemented for a resident assessed to have wandering/exit seeking behaviors. LPN #2 stated, .I would know in my mind. I would go by intuition .Don't look at a score . During an interview on 6/17/2020 at 10:40 AM, the Director of Nursing (DON) was asked what interventions the facility had implemented for wandering behaviors after completion of the Risk Assessment scale for Resident #1 and #7. The DON stated, .The score didn't mean anything .We don't have interventions for risks . Review of the Nurse's Notes dated 1/4/2020, showed Resident #7 was talking in the hall to the air and laughing continually. He was redirected without success and he continued to talk to imaginary people and laugh. He would pick at his shunt site and believed it was something growing inside of him. Review of the Nurse's Note dated 1/11/2020, showed Resident #7 continued to talk in different voices to himself, he would make noises like a dog crying/howling, and stated he was acting like a dog. Review of the Nurse's Note dated 2/4/2020, showed, .Instructed and Encouraged not to pick at the open wound .Discussed potential for infection .was unable to reteach information I (nurse) shared with him . These behaviors were documented, though Resident #7 had been assessed as cognitively intact for decision making. Review of the quarterly MDS assessment dated [DATE], showed Resident #7 scored a 15 on the Basic Interview for Mental Status (BIMS) scale, which indicated the resident was cognitively intact for decision making. Review of a Nurse's Note dated 2/10/2020 at 3:55 PM, showed .Resident (Resident #7) was found in parking lot by kitchen by restorative tech (technician) .stated, I am going to the store . Review of Resident #7's Care Plan dated 2/11/2020, showed the resident wore a wanderguard at all times related to risk for wandering/elopement as evidenced by sitting outside door. During an interview on 6/21/2020 at 2:15 PM, the Restorative Technician stated, .On that day (2/10/2020) I was leaving for lunch by the door next to therapy .it has a key pad but during the day anyone can come and go as pleased, it was not locked .that was before COVID (Coronavirus Pandemic) .I saw (Named Resident #7) in his wheelchair wheeling in the driveway down by the dumpsters headed to the front parking lot area .I yelled his name and he took off trying to go faster down the driveway to the front area .I asked where he was going and he said to the store to get cigarettes .I took him back into the facility .I told his nurse . Review of Resident #7's Nurse's Note dated 4/7/2020 at 6:31 PM, showed .6 pm (6:00 PM) couldn't find resident about 30 minutes and when we did he was coming out of Physical Therapy (PT) unit with bag of jelly beans candy .that he said he went in a drawer in there and took. The unit was closed for the day .He also said that he had tried to get out of a window but couldn't. Was told again not to leave the floor multiple times before this incident . During an interview on 6/19/2020 at 11:30 AM, the Restorative Technician stated, .Yeah on morning of 4/8/2020 when I came in that window (pointed at therapy room window) was open. We don't know how he (Resident #7) got in room, room is locked at night . During an interview on 6/19/2020 at 12:30 PM, the Rehabilitation Manager stated, .On 4/8/2020 he (Resident #7) stopped the therapist in hallway and said he took screen out and tried to crawl out the window but they caught him that night (4/7/2020) before .We saw on 4/8/2020 that morning the window partially open in the department and screen out . The Rehabilitation Manager stated there was no intervention put in place. During an interview on 6/20/2020 at 3:30 PM, Resident #7 stated, .I just opened the door to therapy and went in .In therapy I raised the window all the way .I tried to get out but I fell down and couldn't get out .No one was there .I was coming out (of therapy department) and staff saw me .that is when I told them . During an interview on 6/21/2020 at 1:20 PM, LPN #2 confirmed that she had written the Nurse's Note dated 4/7/2020 at 6:31 PM and stated, .He casually told me what he done, that he had opened a window and tried to get out in the therapy room. I didn't go into the therapy room to check .It was at change of shift .He is a rambler .He is simple minded .No, no one went into the room to check the window . Observations in the Physical Therapy Department on 6/19/2020 at 11:30 AM, with the Administrator, Interim Administrator, and the Maintenance Technician, showed 8 windows. Each window was 24 inches wide and opened 26 inches. The Administrator, Interim Administrator and Maintenance Technician confirmed all the windows could open to 26 inches. Observations in Hall 1 and 2 on 6/19/2020 during tour of the facility, showed the windows in the residents' rooms and the skilled dining room were 24 inches wide and opened 26 inches. During an interview on 6/19/2020 at 2:00 PM, the Director of Maintenance stated, .Yes, all windows open completely . Review of the Nurse's Note dated 5/5/2020 at 2:42 AM, showed, .Resident (Resident #7) stated I need to tell you what I did because it's bad and didn't work out like I wanted to. Resident continued saying he kicked out the screen to his window and window raised with a blanket thrown outside .This nurse went to fix screen on window then called administrator .Resident stated his whole plan for escape to this nurse . The facility staff confirmed this incident occurred the night of 5/4/2020. During an interview on 6/19/2020 at 12:35 PM, MDS Coordinator #2 stated, .I don't see any immediate interventions on the Care Plan for 5/4/2020 event and don't recall any intervention and don't see anything either . During an interview on 6/19/2020 at 12:35 PM, the Administrator stated, .We did not complete an incident report as per policy .we did not investigate the elopement attempt on 5/4/2020 .I was made aware that day .there was no immediate intervention . During an interview on 6/20/2020 at 3:30 PM, Resident #7 stated, .I wanted to leave and opened my window and threw out a blanket .I would like to go home and be with daddy . The Administrator confirmed there were no interventions implemented when Resident #7 attempted to elope through the Rehabilitation Department window or the window in his room. The surveyors verified the Removal Plan by: 1. Residents will not be allowed to exit the building without supervision, effective 6/6/2020. Staff members in all departments were educated that residents are not allowed to be outside the building without supervision. Education began 6/7/2020 and all staff have since been educated. The surveyors confirmed this by reviewing the in-service records and interviews with staff on all shifts. 2. Signage reminding staff of the supervision requirement is posted on all exit doors, completed on 6/7/2020. The surveyors viewed the signage. 3. Residents are being reassessed using the wandering risk scale. Assessments were completed by 6/17/2020. A decision tree related to wandering/elopement has been developed and distributed to the nursing departments for use to assist with determining need for WanderGuard. This is a tool to assist nursing in the decision making process and was completed on 6/17/2020. Interventions were defined to coincide with the wandering risk scale so that staff would be able to successfully identify appropriate interventions for each risk level, completed 6/18/2020. Those interventions are: Score 0-8 - LOW RISK Allow resident to wander if the environment is safe and secure (the area does not contain hazards to the health and safety of the resident). Speak to resident in calm manner and redirect when needed. Provide a safe, uncluttered, path for people to wander and places to rest. If actively seeking exit - assess for Wanderguard. Score 9-10 - MODERATE RISK Allow resident to wander if the environment is safe and secure (the area does not contain hazards to the health and safety of the resident). Speak to resident in calm manner and redirect when needed. Provide a safe, uncluttered, path for people to wander and places to rest. Behavioral monitoring each shift and as needed documented on the Medication Administration Record (MAR). Ongoing activity programs to minimize aimless wandering tendencies. Discuss with interdisciplinary team at next meeting and update resident's care plan. If actively seeking exit - assess for Wanderguard. Score >11 - HIGH RISK Allow resident to wander if the environment is safe and secure (the area does not contain hazards to the health and safety of the resident). Speak to resident in calm manner and redirect when needed. Provide a safe, uncluttered, path for people to wander and places to rest. Behavioral monitoring twice shift and as needed documented on the MAR Attempt to identify the source of stress/agitation contributing to the wandering behavior. Document the types of conversation that may have triggered the resident to increased wandering. Ongoing activity programs to minimize aimless wandering tendencies. Discuss with interdisciplinary team at next meeting and update residents' care plan. If actively seeking exit - assess for Wanderguard. Staff education on the changes of these interventions has commenced as of 6/17/2020 and all nursing staff will be educated before being allowed to work. The surveyors confirmed this by review of the Wandering Risk Assessments, review of the in-service records, and interviews with staff on all shifts. 4. In order to identify residents who are high risk for elopement, the following steps have been taken: List of high elopement risk residents is distributed daily to the following locations: Nursing stations EVS (Environmental Service) carts Dietary office Activities office Therapy office The surveyors confirmed this by reviewing the lists of high elopement risk residents and interviewing staff on all shifts. 5. Monday through Friday, the interdisciplinary team (IDT) will meet to discuss both wandering and exit seeking residents. The surveyors confirmed this by interviews with the IDT members. 6. Daily huddles in the nursing units are used to communicate changes in resident wandering or exit seeking behavior. Behavior monitoring is discussed daily at the nursing huddles. The surveyors confirmed this by interviews with staff. 7. A nursing chart audit tool has been developed to verify compliance with monitoring residents with wandering behaviors which will be completed monthly. The surveyors reviewed the nursing chart audit tool. 8. Behavior monitoring committee meetings will be held weekly as part of the quality assurance program which will be reported to the QA (Quality Assurance) monthly meeting. First was held on 6/18/2020 where the wandering risk assessments completed on 6/17/2020 were discussed and the audit tools for each resident were completed at that time. The QA committee will review the findings of the weekly behavior monitoring committee's minutes and will monitor for effectiveness and compliance. The surveyors interviewed the QA committee members. 9. Management staff assessed windows to ensure they could open no more than 6 to 8 inches on 6/19/2020. Stops were installed to prevent the windows from opening. Management reassessed all facility windows and validated all windows were secured and completed on 6/20/2020. The surveyors observed the windows and interviewed the management staff. 10. Education of nursing staff commenced on 6/19/2020 and was completed on 6/20/2020. The only remaining staff members to be educated include those who are on leave, vacation, or were unreachable by telephone. These staff members will be educated prior to their next shift by their unit coordinator or charge nurse. The education included review of the incident/occurrence policy requiring immediate contact of the facility administrator for incidents surrounding abuse, neglect, exploitation, facility fire, elopement/elopement attempts, and education specifically regarding the interventions for residents exhibiting elopement behaviors and have the documentation of that education for review. The surveyors reviewed the in-service records, education performed, and interviewed staff on all shifts. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on job description review and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to provide oversight to monitor and ensure the training of staff, ensure a safe environment, complete a thorough investigation of elopement and conduct an ad hoc Quality Assurance Performance Improvement (QAPI) committee meeting when two residents eloped from the facility. Administration's failure to ensure a safe environment placed 2 of 15 sampled residents (Resident #1 and #7) in Immediate Jeopardy (IJ) when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was observed by a passing motorist in the 4 lane State highway. The motorist returned the resident to the facility grounds. This resulted in an IJ for Resident #1. Resident #7, a a vulnerable resident, exited the building unsupervised, attempted elopement through a window in the Rehabilitation Therapy Department, and attempted elopement through a window in his room. This resulted in an IJ for Resident #7. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Interim Administrator were notified of Immediate Jeopardy (IJ) on 6/17/2020 at 4:12 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-610, F-689, F-835, and F-867. The facility was cited at F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 2/10/2020 through 6/20/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 6/20/2020 at 3:00 PM and was validated onsite by the surveyors on 6/21/2020 through policy review, observation, medical record review, review of in-service training records, and staff interviews. The findings include: Review of the facility's Administrator job description dated 10/26/2015, showed, .Establish and direct overall operation to provide resident care and ensure compliance with established standards, guidelines and regulations to ensure the highest degree of quality care is maintained at all times .Provides leadership and guidance to other leaders and staff in goal setting, problem solving, resource management, and outcome achievement .Incorporates quality improvement and resident satisfaction data into departmental goals .Demonstrates a clear understanding of regulations applicable to resident care .Directs programs to ensure compliance with all regulatory agencies .Accurately identifies real/potential problems affecting the agency and implements solutions with follow through and communication .Regularly evaluates the quality of services provided . Review of the facility's Director of Nursing (DON) job description dated 7/29/18, showed, .the DON has 24-hour responsibility for the effective implementation of the philosophy, goals, policies, and procedures of the hospital and the nursing department and their effect on patient care in a designated unit .Provides leadership and guidance to other leaders and staff in goal setting, problem solving, resource management, and outcome achievement .Collaborates with other departments to create systems and problem solve ongoing issues that impact care center/organizational goals and/or resident care delivery .Incorporates quality improvement data and/or resident satisfaction data into departmental goals .Demonstrates a clear understanding of regulations applicable to resident care .Assist the Administrator in development, implementation and evaluation of on-going service programs that assure quality nursing and resident care programs .Oversees Care Center PI (Performance Improvement) program which monitors and evaluates critical aspects of care . During an interview on 6/16/2020 at 12:02 PM, Certified Nursing Assistant (CNA) #1 stated, .When we went outside to look we saw a gentleman and a woman with him (Resident #1). The man was pushing him (in a wheelchair) back up toward the front .The man said they had seen him in the highway . During a telephone interview conducted on 6/17/2020 at 1:32 PM, Licensed Practical nurse (LPN) #1 confirmed she had allowed Resident #1 to go outside the building unsupervised. LPN #1 stated, .It was my poor judgement in letting him out .He had been sitting on the front porch just that week. He had been out by himself then . During an interview on 6/19/2020 at 2:50 PM, the Administrator stated, .We did not complete an incident report as per policy .We did not investigate the elopement attempt .we had no significant intervention for that event (Resident #7's elopement attempt on 4/7/2020) .We did not investigate the elopement attempt on 5/4/2020 .I was made aware that day (5/4/2020) .there was no immediate interventions . During an interview on 6/21/2020 at 1:15 PM, the Administrator stated, .Failed to do an incident report as per policy (for elopement) .did put a wanderguard on him (Resident #7) (2/10/2020) but we did not do an investigation . During an interview on 6/20/2020 at 2:35 PM, the Administrator stated, We have no policy about behaviors or monitoring, just this elopement risk/wanderguard policy dated 4/11/2019 . The Administrator confirmed the facility had no policies on monitoring the care of residents with wandering or exit seeking behaviors based on the wanderguard risk assessment. The Administrator confirmed the incidents involving elopement and exit seeking behaviors were not presented to the Quality Assurance Performance Improvement committee nor was there an ad hoc committee meeting held to discuss the elopement attempts. Refer to F610, F689, and F867. The surveyors verified the Removal Plan by: 1. Administration will ensure effective oversight is in place to monitor and provide a safe resident environment by implementation of the report process. Nursing staff members were educated on the incident occurrence reporting process and was completed on 6/20/2020. This process clarifies the types of events to be immediately reported to the administrator, including elopement attempts. The surveyors reviewed the report process, the in-service records, and interviewed staff on all shifts. 2. Administrator will review and sign off on all incident reports beginning 6/19/2020 once investigation is completed and interventions have been implemented. The surveyors interviewed the Administrator. 3. The Administrator will be monitored by the CEO (Chief Executive Officer) of the health system through monthly reports. The health system CEO will meet monthly onsite with the Administrator to review investigations for the month and will evaluate the thoroughness of those investigations. This monthly review may include staff interviews regarding investigations and visual inspections of noteworthy areas as related to investigations. The surveyors interviewed the Administrator and reviewed the monthly report process. Noncompliance of F-835 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on (Named Health System) Quality Improvement Plan 2020 review, policy review, job description review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program, failed to ensure the completion of a thorough investigation of an incident of elopement and elopement attempts, and failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently in order to provide a safe environment for residents. The failure of the QAPI Committee to ensure systems and processes were in place and systems were consistently followed by staff and administration placed 2 of 15 sampled residents (Resident #1 and #7) in Immediate Jeopardy. Resident #1, a cognitively impaired resident at risk of wandering and exit seeking behavior, eloped from the facility in a wheelchair into a 4 lane state highway and was found by a motorist and was escorted back to the facility. The facility was unaware the resident was missing from the facility. Resident #7, a vulnerable resident, exited the building unsupervised, attempted elopement through a window in the Rehabilitation Therapy Department, and attempted elopement through a window in his room. This resulted in an Immediate Jeopardy for Resident #1 and #7. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Interim Administrator were notified of Immediate Jeopardy (IJ) on 6/17/2020 at 4:12 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-610, F-689, F-835, and F-867. The facility was cited at F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 2/10/2020 through 6/20/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/20/2020 at 3:00 PM, and was validated onsite by the surveyors on 6/21/2020 through policy review, review of audits and meeting minutes, and staff interviews. The findings include: Review of the (Named Health System) Quality Improvement Plan 2020 dated 2/25/2020, showed, .The Organizational Quality Improvement Plan is designed to provide a systematic and organized program for the promotion of safe, quality patient care and services .Philosophy Six Aims of Improvement .(1) Safe (2) Effective (3) Patient-centered (4) Timely .Health System Department Leaders .Department Directors and managers are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will: .Collect data identified and assigned by leadership to include: .Nursing Home Quality Assessment/Performance Improvement (QAPI) Initiatives .Quality Council .The Council's primary function is to set guidelines for organization monitoring and evaluation of patient care and safety .Evaluating the need to reprioritization improvement activities in response to unusual or urgent events identified through measurement and/or changes in the environment of care or community .Framework .Safety - the degree to which [MEDICATION NAME] and environmental risks are minimized for the patient and others .Measure The monitoring and analysis process may include but may not be limited to: .Patient Safety screening, data and reports .Sentinel Event Occurrences and Root Cause Analysis .Any elopement, i.e. (namely) unauthorized departure, of a patient from an around the clock care setting .Improve .Appropriate action will be recommended and implemented to eliminate or reduce variations identified or to improve quality of care . Review of the facility's policy titled, Quality Assurance Performance Improvement, revised 3/15/2019, showed, .Facility has an ongoing quality assessment and assurance committee that includes key members that meets at least quarterly. The committee identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to actions plans .the facility is responsible for setting PI (Performance Improvement) activities that affect health outcomes, resident safety .Performance improvement activities include at a minimum medical errors and adverse resident events. The program will analyze their causes, implement preventive actions and mechanisms that include feedback and learning throughout the facility .Administrative responsibility for the PI plan is delegated to the Administrator or DON (Director of Nursing), who, in turn, assigns certain PI activities to other staff members . Review of the Administrator job description dated 10/26/2015, showed, .basic purpose of the job establish and direct overall operation to provide resident care and ensure compliance with established standards, guidelines and regulations to ensure the highest degree of quality care is maintained at all times .provides leadership and guidance to other leaders and staff in goal setting, problem solving, resource management, and outcome achievement .incorporates quality improvement and resident satisfaction data into departmental goals .demonstrates a clear understanding of regulations applicable to resident care and other care center functions .directs programs to ensure compliance with all regulatory agencies .oversees the care center's participation in the PI program, which monitors and evaluates critical aspects of care .accurately identifies real/potential problems affecting the agency and implements solutions with follow through and communication .is responsible for care center's operational excellence and ensures the agency delivers quality services in accordance with applicable policies, procedures, and professional standards . Review of the DON job description dated 7/29/2018, showed, .basic purpose of the job under the direction of the Administrator, the DON has 24-hr (hour) responsibility for the effective implementation of the philosophy, goals, policies, and procedures .incorporates quality improvement data and/or resident satisfaction data into departmental goals .demonstrates a clear understanding of regulations applicable to resident care and/or other care center functions .assists the Administrator in development, implementation and evaluation of on-going service programs that assure quality nursing and resident care programs consistent with health system mission .monitors/maintains care center compliance with regulatory, accrediting and health system policy for resident services, and environmental and personnel safety .oversees care center PI program which monitors and evaluates critical aspects of care .accurately identifies real/potential problems affecting the service and implements solutions with follow-through and communication .is responsible for care center's operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards . During an interview on 6/19/2020 at 1:15 PM, the Medical Director stated, .I was not aware of the February elopement or the April and May elopement attempts by (Named Resident #7) .It was brought to my attention today about the window situation understand a second attempt at a window, no not brought to my attention until today .that is a notable event that should have been reported and brought to my attention .frustrating .a psych (psychiatric) [DIAGNOSES REDACTED].I was not aware of (Named Resident #1) elopement on 6/6/2020 until today .No, there have been no QAPI ad hoc meetings in 2020 . During an interview on 6/19/2020 at 2:50 PM, the Administrator stated, .We did not investigate (Resident #7's) elopement on 2/10/2020, elopement attempts on 4/7/2020 and 5/4/2020 . The Administrator confirmed the incidents concerning Resident #1 and Resident #7 were not taken to QAPI nor was an ad hoc committee meeting held. The facility's QAPI Committee failed to identify the need for an ad hoc meeting to discuss Resident #1 and #7's elopement attempts, failed to investigate Resident #7's elopement and attempts for elopement thoroughly, failed to analyze the situation, failed to evaluate possible regulatory concerns related to Resident #7's elopement and multiple elopement attempts from the facility, and failed to ensure the safety of the residents with wandering or exit seeking behaviors. Refer to F-610, F-689, and F-835. The surveyors verified the Removal Plan by: 1. The Administrator implemented a Behavior Monitoring Committee with meetings to be held weekly as part of the QAPI program. The first meeting was held 6/18/2020 at 11:00 AM. The wandering risk assessments that were completed on 6/17/2020 were discussed and the audit tool was reviewed that verified compliance with monitoring residents with wandering behaviors. This was confirmed by review of meeting minutes dated 6/18/2020 and interview with the committee members. 2. Behavior monitoring committee meetings will be held weekly as part of the quality assurance program which will be reported to the QAPI monthly meeting. In the first meeting held 6/18/2020 the wandering risk assessments completed on 6/17/2020 were discussed and the audit tools were completed for each resident at that time. This was confirmed by review of the meeting minutes, the audit tools, and interviews with the committee members. 3. The DON implemented a Nursing Chart Audit Tool to ensure documentation and assessments of wandering behaviors were thorough and current for the resident. The Minimum Data Set (MDS) Coordinator will oversee the audits of the tool to be completed by the nursing staff. This was confirmed by review of the audit tool and interviews with MDS staff. 4. The QAPI committee will review the findings of the weekly behavior monitoring committee's minutes and will monitor for effectiveness and compliance. This was confirmed by interview with the Administrator. 5. The Chief Executive Officer (CEO) (or designee) of the health system will monitor the actions of the QAPI committee through review of meeting minutes and reports. The CEO will meet monthly onsite with the Administrator to review investigations for the month and will evaluate the thoroughness of those investigations, he will review the QAPI minutes as well. This was confirmed by interview with the Administrator. Noncompliance of F-867 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 2 sampled residents (Resident #7) that was assessed as a risk for wandering. Resident #7 eloped from the building and had 2 other elopement attempts that were not thoroughly investigated. The facility's failure to complete a thorough investigation caused potential elopements for wandering residents, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Administrator were notified of the Immediate Jeopardy (IJ) on 6/17/2020 at 4:12 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 2/10/2020 through 6/20/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/20/2020 at 3:00 PM. The corrective actions were validated onsite by the surveyors on 6/21/2020 through policy review, observations, medical record review, in-service education record review, and staff interviews. The findings include: Review of the facility's policy titled, Abuse, Neglect, or Exploitation, reviewed 3/15/2019, showed, .Alleged abuse is reported immediately to Administration and investigated in a manner consistent with applicable law and regulation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .After receiving notification of allegations of abuse, the Abuse Committee consisting of Administrators and DON's (Director of Nursing) will begin investigation . Review of the facility's policy titled, Occurrence reports/Incident investigation Reportable Events, reviewed 9/2015, showed, .An occurrence report (incident investigation) form is to be completed when an unusual or reportable event occurs or there is a variance from established policy and/or procedures .As soon as an occurrence/incident has been identified, report it to your immediate supervisor and physician, as necessary .Administrator will be notified of occurrences/incidents in daily safety huddle or immediately, if necessary . Review of the facility's policy titled, Elopement Risk/Wander Guard, policy revised 4/11/2019, showed, .Any resident with an altered mental status who has demonstrated behavior that puts them at risk for wandering/elopement will be considered an elopement risk .Procedure: .2. Complete Reportable Event (Incident report form) when resident attempts elopement . Medical record review showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering Risk assessment dated [DATE], showed that Resident #7 had a score of 7, which indicated the resident was at low risk for wandering and propelled himself up and down the hallway. Review of the Nurse's Notes dated 1/4/2020, showed Resident #7 was talking in the hall to the air and laughing continually. He was redirected without success and he continued to talk to imaginary people and laugh. He would pick at his shunt site and believed it was something growing inside of him. Review of the Nurse's Note dated 1/11/2020, showed Resident #7 continued to talk in different voices to himself, he would make noises like a dog crying/howling, and stated he was acting like a dog. Review of the Nurse's Note dated 2/4/2020, showed, .Instructed and Encouraged not to pick at the open wound .Discussed potential for infection .was unable to reteach information I (nurse) shared with him . These behaviors were documented, though Resident #7 had been assessed as cognitively intact for decision making. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 scored a 15 on the Basic Interview for Mental Status (BIMS) scale, which indicated the resident was cognitively intact for decision making. Review of the Nurse's Note dated 2/10/2020 at 3:55 PM, showed, .Resident (Resident #7) was found in parking lot by kitchen by restorative tech (technician) .stated, I am going to the store . During an interview on 6/21/2020 at 2:15 PM, the Restorative Technician stated, .On that day (2/10/2020) I was leaving for lunch by the door next to therapy .it has a key pad but during day anyone can come and go as pleased, it was not locked .that was before COVID (coronavirus pandemic) .I saw (Named Resident #7) in his wheelchair wheeling in the driveway down by the dumpsters headed to the front parking lot area .I yelled his name and he took off trying to go faster down the driveway to the front area .I asked where he was going and he said to the store to get cigarettes .I took him back into the facility .I told his nurse . During an interview on 6/21/2020 at 1:15 PM, the Administrator stated, .Failed to do an incident report as per policy (for elopement) .did put a wanderguard on him (Resident #7) (2/10/2020) but we did not do an investigation . Review of the Nurse's Note dated 4/7/2020 at 6:31 PM, showed, .6 (6:00) pm couldn't find resident (Resident #7) about 30 minutes and when we did he was coming out of Physical Therapy (PT) unit with bag of jelly beans candy .that he said he went in a drawer in there and took. The unit was closed for the day .He also said that he had tried to get out of a window but couldn't. Was told again not to leave the floor multiple times before this incident . Observation in the Physical Therapy Department on 6/19/2020 at 11:30 AM, showed 8 windows. Each window was 24 inches wide and opened 26 inches. The Administrator, Interim Administrator, and Maintenance Technician were present during the observation and confirmed all the windows opened to 26 inches. Observations in Hall 1 and 2 on 6/19/2020 showed the windows in the residents' rooms and skilled dining room were 24 inches wide and opened 26 inches. During an interview on 6/19/2020 at 11:30 AM, the Restorative Technician stated, .Yeah on morning of 4/8/2020 when I came in that window (pointed at window in PT department) was open. We don't know how he (Resident #7) got in room, room is locked at night . During an interview on 6/19/2020 at 12:30 PM, the Rehabilitation Manager stated, .On 4/8/2020 he (Resident #7) stopped the therapist in hallway and said he took screen out and tried to crawl out the window but they caught him that night (4/7/2020) before .We saw on 4/8/2020 that morning the window partially open in the department and screen out . The Rehabilitation Manager stated there was no intervention put in place for the attempted elopement through the window. During an interview on 6/19/2020 at 2:00 PM, the Director of Maintenance stated, .Yes, all windows open completely . During an interview on 6/19/2020 at 2:50 PM, the Administrator stated, .We did not complete an incident report as per policy .we did not investigate the elopement attempt .we had no significant intervention for that event (4/7/2020) . During an interview on 6/20/2020 at 3:30 PM, Resident #7 stated, .I just opened the door to therapy and went in .In therapy I raised the window all the way .I tried to get out but I fell down and couldn't get out .No one was there .I was coming out (of therapy department) and staff saw me .that is when I told them . During an interview on 6/21/2020 at 1:20 PM, Licensed Practical Nurse (LPN) #2 confirmed that she had written the Nurse's Note dated 4/7/2020 at 6:31 PM. She stated, .He (Resident #7) casually told me what he done, that he had opened a window and tried to get out in the therapy room. I didn't go into the therapy room to check .It was at change of shift .He is a rambler .He is simple minded .No, no one went into the room to check the window . Review of the Nurse's Note dated 5/5/2020 at 2:42 AM, showed, .Resident (Resident #7) stated I need to tell you what I did because it's bad and didn't work out like I wanted to. Resident continued saying he kicked out the screen to his window and window raised with a blanket thrown outside .This nurse went to fix screen on window then called administrator .Resident stated his whole plan for escape to this nurse . The facility staff confirmed this incident occurred the night of 5/4/2020. During an interview on 6/19/2020 at 12:35 PM, the Administrator confirmed there was no investigation or intervention put in place and stated, .We did not complete an incident report as per policy .we did not investigate the elopement attempt on 5/4/2020 .I was made aware that day .there was no immediate intervention . During an interview on 6/19/2020 at 1:15 PM, the Medical Director stated, .I was not aware of the February elopement or the April and May elopement attempts by Mr. (Resident #7) .It was brought to my attention today about the window situation, understand a second attempt at a window, no not brought to my attention until today .that is a notable event that should have been reported and brought to my attention .frustrating .a psych (psychiatric) [DIAGNOSES REDACTED]. During an interview on 6/20/2020 at 3:30 PM, Resident #7 stated, .I wanted to leave and opened my window and threw out a blanket .I would like to go home and be with daddy . The facility failed to ensure a thorough and complete investigation was conducted when Resident #7, a vulnerable resident, exited the building on 2/10/2020, attempted elopement through a window on 4/7/2020 and again on 5/4/2020, which resulted in an Immediate Jeopardy for Resident #7. The surveyors verified the Removal Plan by: 1. Staff will report elopement attempts to the Administrator (or Director of Nursing) at the time of the attempt. Investigation of the attempt will commence at that time. This was confirmed by policy review and interviews with staff on each shift. 2. Behaviors, to include elopement attempts, will be discussed with interdisciplinary team at next meeting and update resident's Care Plan. This was confirmed by interviews with the interdisciplinary team and review of residents' care plans. 3. Management staff assessed windows to ensure they could open no more that 6 to 8 inches on 6/19/2020. Stops were installed to prevent the windows from opening. Staff is actively inspecting all windows and should have inspection, any needed remediation, and documentation completed by 6/20/2020. This was confirmed by reviewing audit forms and audits of windows. 4. Education of nursing staff began on 6/19/2020 and was completed by 6/20/2020. The education included review of the incident/occurrence policy requiring immediate contact of the facility administrator for incidents surrounding abuse, neglect, exploitation, facility fire, and elopement/elopement attempts. Education was conducted with nursing staff regarding reporting elopement/elopement attempts and included education on the occurrence report form, which is the tool used to ensure information is collected in order to conduct a thorough investigation. Nursing staff will not be allowed to work until education is complete. This was confirmed by review of in-service sign in sheets and interviews with staff on each shift. 5. The maintenance department will audit and log windows on a weekly basis to verify that they do not open greater than 6 - 8. This was confirmed by reviewing the audit forms, observations of the windows, and interviews with maintenance staff. 6. Auditing and monitoring of the investigation/incident reports will be conducted using the investigation [MEDICATION NAME] form. This form will be reviewed at the weekly fall/behavioral management meetings, and that information will be sent to the QAPI committee. This was confirmed by reviewing the investigation [MEDICATION NAME] form. Noncompliance at F-610 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, review of the Medical Director's job description, review of the Director of Nursing (DON) job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program recognized an ongoing concern related to smoking safety, residents with elopement risks that had knowledge of exit door codes and nonfunctioning wanderguard sensors on exit doors. The QAPI committee failed to ensure the facility identified the root cause of the concerns, developed appropriate plans of action, ensured systems and processes were in place and were consistently followed by staff to address quality concerns. The QAPI committee failed to ensure interventions to prevent unsupervised smoking were consistently implemented or followed, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, that the Medical Director assisted the facility with identifying, evaluating, and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the implementation of resident care policies and procedures for residents that smoke and for residents with risk of elopement. The QAPI committee failed to ensure smoking and wandering assessments were timely and accurate. The failure of the QAPI Committee to ensure the facility implemented and/or provided care and services for the residents that smoked and demonstrated exit seeking behaviors placed 5 of 5 residents in Immediate Jeopardy (IJ) when Resident #22, #30, #88, #102, and #180 smoked without supervision and safe smoking care interventions were not provided as recommended. The failure of the QAPI Committee to ensure the facility implemented and/or provided care and services for the residents that demonstrated exit seeking behaviors placed 7 of 7 residents in Immediate Jeopardy when Resident #2, #12, #13, #18, #38, #70, and #377 had nonfunctioning wanderguards and door sensors, and maintenance failed to identify the sensor doors as nonfunctional. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist for the health system, and the Minimum Data Set (MDS) Coordinator, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited a scope and severity of Immediate Jeopardy for F657-K, F689-K, F835-K, F841-K, and F867-K. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An extended survey was conducted on 7/12/19 through 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F867-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Interim Administrator Contract dated 4/12/19 documented, .This Agreement shall be governed by and construed in accordance with the laws of the State of Tennessee .The Contractor agrees to .Oversees all activities of the care center in accordance with established policies and federal and state guidelines .Develop strategic plans for profitability and accountability for all operations and programs .Administer, direct and coordinate the business .Recommend and lead changes to improve the care center .Maintain a state administrator license .Create functional strategies and specific objectives for the care center and develop budgets/policies/procedures to support the functional infrastructure .Implement Administrator -in-Training Program . 2. The facility's Director of Nursing Job Description dated 6/17/19 documented, .Under the direction of the Administrator, the DON has 24-hour responsibility for the effective implementation of the philosophy, goals, policies, and procedures of the hospital and the nursing department and their effect on patient care in a designated unit.Evaluates on-going programs as assigned by Administrator .Monitors/maintains care center compliance with regulatory, accrediting and health system policy for resident services, and environmental and personnel safety .Monitors the staff's understanding of established emergency .and/or universal precautions procedures as evidenced by PI (Performance Improvement) reports, incident follow-ups, staff meeting minutes and direct observation by Administrator .Oversees Care Center PI program which monitors and evaluates critical aspects of care .Accurately identifies real/potential problems affecting the services and implements solutions with follow-through and communications .Is responsible for care center's operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards . 3. The facility's Medical Director job description dated 7/2016 documented, .The Medical Director is a licensed physician in this state and is responsible for .Overseeing and helping develop and implement care-related policies and practices .Participating in efforts to improve quality of care and services .Acting as a consultant to the director of nursing services in matters relating to resident care services .Helping assure that residents receive adequate services appropriate to meet their needs .Helping assure that the resident care plan accurately reflects the medical regimen .Participating in staff meetings concerning .quality assurance and performance improvement .resident care policies .Assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care . Interview with the Interim Administrator on 7/13/19 at 3:08 PM, in the Conference Room, the Interim Administrator was asked if the Quality Assurance Committee (QAC) developed appropriate plans of action for smoking or elopements. The Interim Administrator confirmed that the QAC had not discussed the smoking concerns or the security door issue. The Interim Administrator was asked if the QAC had discussed the problem with the doors. The Interim Administrator confirmed he had discovered the problem at the same time we (surveyors) did during the survey this week. The Interim Administrator stated, .My spot checking that I did with (Facilities Director) was good, I just checked the wrong doors . 5. The Facility's QAPI committee failed to identify, develop, and implement appropriate plans of action to ensure care plans were reviewed, updated, and implemented for care of residents with diminished safety awareness.This resulted in IJ for Resident #22, #30, #88, #102, and #180. Refer to F657. 6. The QAPI Committee failed to provide an acceptable standard of care for residents with diminished safety awareness and to prevent elopement. This resulted in Immediate Jeopardy for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #180 and #377. Refer to F689. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 A.M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan for smoking safely with effective interventions to prevent accidents for 5 of 5 (Resident #22, #102, #30, #88, and #180) sampled residents reviewed for smoking which placed these residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist Director, and Minimum Data Set (MDS) Coordinator #2, were notified of the IJ on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited at scope and severity of Immediate Jeopardy for F657-K. The extended survey was conducted on 7/12/19 through 7/15/19. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F657-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Care Plan policy with a revision date of 10/23/18 documented, .PURPOSE .To provide guidelines for identifying a resident's care needs .To provide guidelines for structuring an approach through interventions to address their care needs .An individualized care plan will be established for each resident to provide effective and person centered care .New Care Plans will be initiated as new needs are identified in order to meet the individualized needs of each resident .The plan should be kept current and flexible to meet the resident's changing problems or needs . 2. The facility's Smoking Policy dated 12/94 and revised 4/11/19 documented, .Residents who were admitted prior to 11/15/12 will be allowed to continue smoking until their discharge .All resident smoking materials are to be kept secured by the facility .Visitors need to check with charge nurse/nurse before giving smoking materials to ANY resident of Care Centers . 3. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's Care Plan for smoking was dated 1/29/18. The Care Plan interventions for smoking had not been revised since the care plan was initiated on 1/29/18. Medical record review of Resident #22's care plan for falls dated 1/29/18 with revisions documented the following: .2/15/19 .Interventions .Resident was witnessed going outside through breakroom door at skilled care and tipping over to the right as his wheels went off side walk pavement .Fence beside side walk was pushed over during the fall. Skin tears to right arm and elbow. Resident counseled to not use this door in the future. Sign posted to keep breakroom door closed and door to outside locked at all times . Medical record review of a MDS assessment dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated Resident #22 was severely cognitively impaired and was non-compliant. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #22 was smoking without staff supervision. 3. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS assessment for Resident #102 dated 3/13/19 documented a BIMS score of 12 which indicated Resident #102 was moderately impaired cognitively. A Web Event Summary Report dated 3/23/19 documented, .At 7:30 pm tech (technician) noted cigarette burn to abdomen, ashes in navel, burn hole in pants. Area not draining or wet. Dry with slight redness around it . Medical record review of the Order Audit Report for Resident #102 dated 3/25/19 documented, .Resident to be supervised at all times while smoking (Do Not leave alone while smoking) . The care plan intervention was revised on 4/12/19 for Resident #102 to smoke unsupervised. The care plan for smoking for Resident #102 was not revised until 4/12/19. Revision of the care plan on 6/27/19 documented, .RESIDENT MUST BE SUPERVISED/ACCOMPANIED BY STAFF WHILE SMOKING .RESIDENT IS NOT TO BE LEFT ALONE WHILE SMOKING . Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM, revealed Resident #102 smoking without staff supervision. Interview with MDS Coordinator #1 on 7/10/19 at 10:30 AM, in the Conference Room, MDS Coordinator #1 was asked if the care plan was updated. MDS Coordinator #1 stated, I need to look at his (physician) progress note. I will get with him for a clarification order. MDS Coordinator #1 failed to answer whether the care plan had been revised. Interview with MDS Coordinator #2 on 7/12/19 at 10:50 AM, in the Conference Room, MDS Cordiantor #2 was asked why Resident #102 had the intervention to be supervised while smoking on 6/27/19. MDS Coordinator #2 stated, .I am not sure .we have been talking about it . Interview with MDS Coordinator #1 on 7/12/19 beginning at 11:04 AM, in the Conference Room, MDS Coordinator #1 was asked about the care plan not being revised for Resident #102 after a burn was found on Resident #102's abdomen. MDS Coordinator #1 stated, .we did not have a care plan meeting, we did not have time for a meeting that week . 4. Medical record review revealed Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 3/30/19 documented, .Behavior is rebellious over the last week. Has been sneaking outside to smoke with another patient despite being told that someone either staff or family must accompany him . Resident #30 did not have a care plan for smoking when he was admitted on [DATE]. Resident #30's care plan was not revised to reflect elopement risk related to history of attempts to leave the facility unattended and impaired safety awareness status until 4/4/19. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #30 smoking without staff supervision. 5. Medical record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 3/17/16 for Resident #88 documented, .6/24/19 .Resident is grandfathered in (allowed to smoke) but must smoke in designated area smoke at designated times . Resident #88 was transferred from (Named facility) sister building to present building on 9/19/18. Medical record review of an annual MDS dated [DATE] documented Resident #88 had a BIMS score of 12 which indicated moderate cognitive impairment and had functional impairment to both arm and leg on one side of his body. The smoking care plan for Resident #88 was not revised until 6/24/19. According to the facility's policy there was no designated times for supervised smoking and the smoking materials were to be secured by the facility. 6. Medical record review revealed Resident #180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission MDS dated [DATE] documented Resident #180 had a BIMS score of 12 which indicated moderate cognitive impairment and he had impairment on one side of his body. Medical record review of a Care Plan for Resident #180 dated 12/20/18 revealed Resident #180's care plan did not address smoking and noncompliance by the resident. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #180 smoking without staff supervision. Interview with MDS Coordinator #1 on 7/10/19 at 10:30 AM, in the Conference Room, MDS Coordinator #1 confirmed the care plans were not revised to reflect smoking safely with effective interventions to prevent accidents. Refer to F689. The surveyors verified the A[NAME] by: The Interdisciplinary Team, consisting of the DON, ADON, Infection Preventionist, Activity Director, MDS Coordinators, Dietician, and Social Services will meet daily after morning meeting, to assure review of any updates and revisions to the resident care plans are occurring, appropriately and accurately and that those changes are being properly communicated to the licensed nurses, direct care and dietary staff members. An updated communication system has been developed whereby changes entered into the residents' care plan are updated on the electronic documentation system. Those changes will be reflected on the Nurse Aide Kardex and any significant issues will be discussed face to face during the daily nursing staff huddles and during shift report. The care plans of residents who smoke have been updated to reflect the current Smoking Policy. These care plans will be updated at least quarterly or as necessary by the MDS Coordinators. Being that the facility is going Smoke Free on 8/12/19 newly admitted residents, who smoke, will be educated regarding the Smoke Free policy and will be reflected on their care plans. The surveyors interviewed the ADON and were provided information to review when the care plans will be updated. Audits will be completed to ensure updates are maintained. Noncompliance continues at a scope and severity level of [NAME] for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided supervision to eliminate the risk of elopement and accidents for 9 of 9 (Resident #22, #102, #18, #12, #13, #38, #2, #70, and #377) wandering and smoking residents reviewed and failed to ensure residents were supervised while smoking to prevent accident hazards for 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents. The 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents also had knowledge and used the exit door key pad codes provided to them by the staff, allowing the residents to exit the building independently without staff supervision, were allowed to smoke unsupervised, and were allowed to keep smoking materials (cigarettes and lighters) on their person. The 7 of 7 (Resident #2, #12, #13, #18, #38, #70, and #377) cognitively impaired, vulnerable residents with wanderguards (ankle band tracking system that automatically locked the doors and alarmed) were at elopement risk, when the facility had nonfunctioning sensor alarms or no sensor alarms on 5 of 8 (Hall 1 door, Hall 2 Dining Room door, Hall 3 Dining Room door, Hall 4 West door, and Hall 6 door) exit doors. The facility was 156 feet from a heavily traveled 4 lane state highway. The failure of the facility to provide supervision and to prevent accidents resulted in HARM when Resident #22 and #102 had falls with injury when these residents were allowed to use the exit code to the doors to leave a safe area to an unsafe area. The failure of the facility to ensure the exit doors had functioning wanderguard sensor alarms and the failure to check and repair the exit doors placed Resident #12, #13, and #18 in Immediate Jeopardy when these residents with wanderguards were able to exit the building, and this had the potential to affect the other wandering residents (Resident #2, #38, #70, and #377). The failure of the facility to provide supervision during smoking had the potential to cause serious harm or injury, and placed Resident #22, #30, #88, #102, and #180 in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. An extended survey was conducted on 7/12/19 through 7/15/19. The Interim Administrator, the Assistant Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Quality and Infection Preventionist Director, the Infection Preventionist, and Minimum Data Set (MDS) Coordinator #2 were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited IJ at F689 K which is Substandard Quality of Care. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The Immediate Jeopardy was effective from 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. The noncompliance continues at F689-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Smoking Policy with a revision date of 4/11/19 documented, .OBJECTIVE .To restrict smoking to a minimum and reduce risks to residents .who smoke, including adverse effects .the risk of fire .All resident smoking materials are to be kept secured by the facility .Visitors need to check with charge nurse/nurse before giving smoking materials to ANY resident of Care Centers . The facility's Oxygen Administration - Hazards and Pitfalls policy with a revision date of 9/17 documented, .The most frequent cause of fire when oxygen is being administered is the lighting of a cigarette. This hazard is greatly increased with the administration of oxygen. Smoking is strictly against the rules and regulations in rooms where oxygen is being administered . Review of the facility's Elopement Risk/ Wanderguard policy with a revision date of 4/11/19 documented, .Any resident with an altered mental status who has demonstrated behavior that puts them at risk for wandering/elopement will be considered an elopement risk .PR[NAME]EDURE .Document behavior in Nursing Notes. Be descriptive as to behavior resident is demonstrating .Resident will wear wanderguard bracelet . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a MORSE FALL SCALE assessment dated [DATE] documented, .Moderate Risk for Falling . Medical record review of the Care Plan for Resident #22 revised on 7/8/19 documented, .The resident is (Moderate) risk for falls .Interventions .2/15/19 Resident was witnessed (staff witnessed from inside the building) going outside through (employee) breakroom door at skilled care and tipping over to the right as his wheels went off sidewalk pavement. Fence beside side walk was pushed over during the fall. Skin tears to right arm and elbow. Resident counseled to not use this door in the future. Sign posted to keep breakroom door closed and door to outside locked at all times . Medical record review of a Nurses Progress Incident Note dated 2/15/19 at 12:52 PM documented, .at 0645 (6:45 AM) this am pt (patient) went outside to smoke. he (He) went out the staff lounge door. he (He) was reaching for the door knob to come back into building when his w/c (wheelchair) tipped over the edge of the sidewalk. he (He) and the w/c was found lying on the white fence that was knocked over. he (He) was lying on his rt (right) side. his (His) rt arm has 3 large skin tears and some bruising . Medical record review of a Progress Note Skin/Wound Note dated 2/15/19 at 1:45 PM documented, .3 skin tears to right arm noted .Re-approximated 2 skin tears with steri strips (wound closure device used instead of stitches) . Review of a Web Event Summary Report dated 2/15/19 documented, .Resident (#22) was exiting the building in wheelchair through skilled breakroom when his wheelchair wheels on the right side fell off the pavement causing him to turn over to the right side against a fence that fell over with him .Assisted up x (times) 4 staff members. Skin tears to right arm .Resident (#22) counseled to not attempt to go outside unassisted. Doors to breakroom are to be kept closed at all times (punch lock for staff only) and doors to outside are to be locked at all times. resident (Resident) and staff voice understanding . Medical record review of the admission MDS dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, and required limited to extensive staff assistance with activities of daily living (ADLs). Medical record review of a MORSE FALL SCALE assessment for Resident #22 dated 7/8/19 documented, .High Risk for Falling . Interview with Licensed Practical Nurse (LPN) #4 on 7/12/19 at 11:04 AM, in the Conference Room, LPN #4 stated, .I was in the skilled hall and I glanced out window I saw his (Resident #22) arm go up and a body go up. He was outside .said he was reaching to let himself back in .he got there alone .I would call that a witnessed fall . Observations at the Hall 6 Smoking Porch Exit door on 7/8/19 at 12:51 PM, revealed Resident #22 propelled himself to the door and entered a code in the door lock key pad, opened the door with the metal handicap push button, and entered the Smoking Porch. Interview with the ADON on 7/11/19 at 2:35 PM, in the Conference Room, the ADON was asked if Resident #22 had a fall. The ADON confirmed he went into the break room and out the side door, and he turned over his wheelchair. The ADON stated, I'm not sure how he got into the break room door. It .has a key pad on it. After getting in the break room, the door to the outside is unlocked. Observations in the courtyard on 7/11/19 at 2:44 PM, revealed the back door of the breakroom lead to the courtyard. The side walk had a drop off. The courtyard was not a secured area. There was not a secured area outside the building. Resident #22 entered an unsafe area from a safe area, unsupervised, and sustained 3 skin tears requiring steri-strips, which resulted in HARM to Resident #22. 3. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan for Resident #102 revised on 6/27/19 documented, .The resident has had an actual fall .Interventions .1/10/19 At 15:30 (3:30 PM) was outside smoking (on Smoking Porch), bent forward to pick up cigarette from ground and fell out of wc (wheelchair) and hit her head .has small hematoma to forehead between eys (eyes), small abrasion to bridge of nose and 5cm (centimeters) x 1.5cm skin tear to shin .Assigned staff supervision with resident when smoking . Review of a Web Event Summary Report dated 1/11/19 documented, .Resident (#102) was outside smoking, she bent forward to pick up cigarette off ground and fell out of wc, hit her head causing a small hematoma to forehead between eyes, and abrasion to bridge of nose and skin tear 5 cm X 1.5 to right shin .steri-strips (wound closure strips) applied The care plan was updated 1/10/19 for Resident #102 to be supervised with smoking. Medical record review of the annual MDS dated [DATE] revealed Resident #102 had a BIMS score of 12, which indicated moderate cognitive impairment. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:51 PM, revealed Resident #102 propelled herself out the door to the Smoking Porch (an unsecured area). Interview with the DON and MDS Coordinator #1 on 7/10/19 at 9:41 AM, in the Conference Room, MDS Coordinator #1 was asked if residents knew the code to the door. MDS Coordinator #1 and the DON confirmed residents did know the code to the Smoking Porch Exit door. The DON and MDS Coordinator #1 were asked if the residents could go freely out to smoke at any time. The DON and MDS Coordinator #1 stated, Yes. Interview with the Interim Administrator on 7/12/19 at 11:35 AM, in the Conference Room, the Interim Administrator was asked if Resident #102 should have been outside alone. The Interim Administrator stated, We (Administrative staff) don't think so, no . Resident #102 entered an unsafe area from a safe area, unsupervised, and sustained a skin tear requiring steri-strips and a hematoma, which resulted in HARM to Resident #102. 4. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change MDS dated [DATE] and the quarterly MDS dated [DATE] revealed a BIMS score of 8, which indicated moderate cognitive impairment. The Web Event Summary dated 9/14/18 documented, .8:30am Resident went out side door of Hall 4, has wanderguard on. Dtr (daughter) .and FNP (Family Nurse Practitioner) notified . Medical record review of the Care Plan for Resident #18 revised 7/8/19 documented, .The resident is an elopement risk/wanderer r/t (related to) Disorientation to place, Impaired safety awareness .Interventions .9/14/18 Resident was able to get outside door. Tech (Certified Nursing Technician) nearby and retrieved resident without incident. Wanderguard in place. Maintenance contacted to check on door security .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers . Medical record review of the WANDERING RISK SCALE assessments dated 1/14/19 and 4/14/19 revealed a score of 10 which indicated At Risk to Wander. Review of a Web Event Summary Report for Resident #18 dated 1/31/19 documented, .(on 1/30/19) Resident was sitting outside door on south hall, CNA (Certified Nursing Assistant) student thought that he was waiting to go smoke and let him outside, resident was found up against fence with wc on top of him, he did have small cut to right 4th finger .Intervention .Neurochecks initiated .student tech educated on protocol on letting residents outside and also which residents are allowed to smoke unattended. Discussed smoking policy and protocal (protocol) for letting residents outside in huddle, also put in task a reminder that resident is not allowed outside unattended . Observations in Resident #18's room on 7/8/19 at 12:15 PM revealed Resident #18 seated in his wheelchair and appeared confused. Interview with the ADON on 7/11/19 at 7:15 PM, in the Conference Room, the ADON confirmed Resident #18 exited the building on 9/14/18 and maintenance was contacted and stated, .not sure why maintenance was notified . Interview with LPN #3 on 7/14/19 at 6:26 PM, in the Fine Dining Room, LPN #3 was asked if there had been any problems with the wanderguards functioning correctly. LPN #3 stated, Some of the wanderguards were not working properly with all the doors .I have seen (Resident #18) .he is very persistent .sometimes it doesn't alarm . 5. Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Web Event Summary Report dated 9/8/18 documented, .2:30 pm Resident and roommate (Resident #13) was outside bldg (building) underneath awning at end of hall 4 .Work order to maintenance to have doors checked . (The Hall 4 West door had a wanderguard sensor that was not functioning appropriately). Medical record review of a Progress Note for Resident #12 dated 9/12/18 documented, .Resident and roommate went to front door on skill hall and attempted to elope. Resident also came to back door by nurse's station and attempted to elope . Review of the physician orders [REDACTED].#12 had a wanderguard since 9/11/18. Medical record review of the annual MDS dated [DATE] revealed a BIMS score of 7, which indicated severe cognitive impairment and used wander/elopement alarms. Medical record review of the Care Plan for Resident #12 revised 7/8/19 documented, .The resident is an elopement risk r/t Impaired safety awareness .Interventions .9/8/18 Resident found standing outside .just getting some fresh air .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers Date Initiated: 09/11/2018 .WANDER ALERT: Wander guard in place Date Initiated: 09/11/2018 . Medical record review of WANDERING RISK SCALE assessments dated 1/3/19, 4/3/19, and 7/3/19 documented, .High Risk to Wander . Observations in Hall 4 on 7/8/19 at 12:20 PM, revealed Resident #12 ambulating on the hall with a rolling walker. Interview with the ADON on 7/14/19 at 4:32 PM, in the Conference Room, the ADON was asked about Resident #12 exiting the building. The ADON stated, .There was a family member or someone else's family member let them out under the awning on Hall 4 . 6. Medical record review revealed Resident #13 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#13 had a wanderguard since 4/24/18. Medical record review of a Web Event Summary Report for Resident #13 dated 9/8/18 documented, .2:30 pm Resident was found with roommate (Resident #12) outside of bldg. underneath awning at end of Hall 4 .has on Wanderguard .Work order to have door checked .9-10-18 . Review of Maintenance Work Orders documented the following: a. 9/10/18 .Door going outside not working properly .hall 5 . b. 9/10/18 .Hall 4 exterior door (where linen is brought in) and the skilled dining room exit door is (are) not locking appropriately (they are suppose to lock automatically) and the wander guard is not working properly on these doors .This needs to be looked at asap (as soon as possible) .Hall 4 exterior door (where linen is brought in) . c. 9/14/18 .Hall 4 doors are not locking down with wander guard .resident (Resident #18) with wander guards opened doors today .Hall 4 (Hall 4 West door)outside doors . There was no documentation the doors were repaired or checked. Medical record review of Progress Notes documented: a. 9/12/18 .Resident and roommate (Resident #12) went to front door on skill hall and attempted to elope. Resident also came to back door by nurse's station and attempted to elope . b. 1/10/19 .has a wander guard in place d/t confusion and risk of elopement . c. 2/12/19 .Roaming halls wanting to leave with pocketbook on shoulder . Medical record review of the quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated severe cognitive impairment, and daily use of a wander/elopement alarm (wanderguard). Medical record review of the WANDERING RISK SCALE assessments for Resident #13 dated 1/4/19, 4/3/19, and 7/8/19 documented, .High Risk to Wander . Medical record review of the Care Plan for Resident #13 revised 7/8/19 documented, .The resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia . Interventions . supervise as needed. Date Initiated: 10/12/2017 .The resident is an elopement risk r/t Impaired safety awareness . Interventions .4/23/18 . Wanderguard anklet applied .9/8/18 Resident found standing just outside door .was getting some fresh air. Resident redirected back into facility without issue. Date Initiated: 09/11/2018 . Observations on Hall 4 on 7/14/19 at 1:57 PM, revealed Resident #13 ambulating in the hall using a rolling walker. She had a wanderguard to her right ankle. Interview with the Facilities Director on 7/12/19 at 12:03 PM, in the Conference Room, the Facilities Director was asked if he had to check the exit doors because a resident had been found outside the building. The Facilities Director stated, No ma'am. Interview with the Maintenance Technician on 7/15/19 at 10:55 AM, in the Conference Room, the Maintenance Technician was asked about the doors that did not alarm or lock on 9/10/18 when a resident with a wanderguard approached. The Maintenance Technician stated, They (staff) told me it just wasn't locking. We had the security guard come over and make sure of the times they (doors) were locking . The Maintenance Technician confirmed the door was not checked or repaired for wanderguard functioning. 7. Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] documented moderate cognitive impairment per staff assessment, required supervision with transfers, walking, and locomotion. Medical record review of the Care Plan for Resident #38 with a revision date of 7/8/19 documented, .The resident is an elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wanders aimlessly .Interventions .Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers .Date Initiated: 05/02/2019 .WANDER GUARD IN PLACE .Date Initiated: 05/02/2019 . Medical Record review of the Wander Elopement Risk Assessments for Resident #38 dated 4/30/19, 6/28/19 and 7/12/19 documented, .High Risk to Wander . Medical record review of Progress Notes dated 4/30/19 through 7/6/19 documented Resident #38 was frequently wandering in and out of other resident rooms, had unsteady gait with stumbling steps noted at times, had exit seeking behaviors, was difficult to redirect, had poor safety awareness, and needed constant supervision. Medical record review of a Progress Note dated 5/4/19 documented, .Resident (#38) has exhibited exit seeking behavior all day. She walks independently without assistive device. Resident walks from door to door trying to get outside. She was observed walking out the front door with a group of visitors on Skilled Care .Unable to redirect resident from exit seeking due to dementia . Observations in the Skilled Hall on 7/8/19 at 11:20 AM revealed Resident #38 was seated in a chair holding a baby doll, oriented to person only, and talking about wanting to get home with the rest of the family. Interview with the ADON on 7/14/19 at 4:27 PM, in the Conference Room, the ADON stated, She (Resident #38) was really hard to redirect .she would walk until she tired herself out .It (behaviors) started 5/2/19 and ended 6/27/19 when she went out to the hospital. The ADON was asked when the wanderguard was reordered and why. The ADON stated, .7/12/19 .She (Resident #38) showed signs of trying to exit seek again . The ADON confirmed Resident #38 had a history of [REDACTED]. 8. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].WANDERGUARD BRACELET AT ALL TIMES every day and night shift for safety . Medical record review of a Progress Note for Resident #2 dated 5/2/19 documented, .Continue to try to get out the front door .said I tried so hard to escape and I could not .Wanderguard on patient left ankle intact . Medical record review of a Progress Note dated 5/5/19 documented, .He has wandered on and off all day. His primary mode of locomotion is by wheelchair. He self propels with his feet, he has tried to exit front doors and is difficult to redirect . Medical record review of a Progress Note for Resident #2 dated 5/10/19 at 9:24 AM documented, .Patient testing doors and wandering up and down hallway and into other patients (patients') rooms. He is difficult to redirect at times and not redirect-able at others . Medical record review of a Progress Note dated 5/10/19 at 12:40 PM documented, .Patient anxious. Testing doors. Propelling self in wheelchair into others (others') rooms . Medical record review of the Care Plan for Resident #2 revised 6/13/19 documented, .The resident has an ADL self-care performance deficit .Interventions .WANDERGUARD BRACELET AT ALL TIMES Date Initiated: 04/04/2019 .The resident has impaired cognitive function/dementia or impaired thought processes r/t memory loss, impaired safety awareness, behavioral symptoms . Interventions . WANDERGUARD BRACELET AT ALL TIMES Date Initiated: 04/04/2019 . Medical record review of the quarterly MDS dated [DATE] revealed moderate cognitive impairment by staff assessment and required the use of wander/elopement alarms. Observations in Resident #2's room on 7/8/19 at 12:35 PM and on 7/8/19 at 4:00 PM, revealed Resident #2 lying in bed, alert with a wanderguard device in place. 9. Medical record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] documented a BIMS score of 3 which indicated severe cognitive impairment, and required staff assistance for all ADLs. Medical record review of Progress Notes dated 3/13/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of the Care Plan for Resident #70 revised 6/4/19 documented, .The resident has impaired cognitive function/dementia or impaired thought processes . Interventions .supervise as needed Date Initiated: 02/23/2018 .Potential for Elopement .Interventions .Wanderguard to be applied (remain in place at all times) d/t possible elopement Date Initiated: 04/19/2018 . Medical record review of Progress Notes dated 6/10/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of a Physician order [REDACTED]. Observations in the South Dining Room on 7/12/19 at 10:13 AM revealed Resident #70 seated in a wheelchair coloring. He was alert and confused, and had a wanderguard to his ankle. 10. Medical record review revealed Resident #377 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 7/9/19 documented, .has been observed ambulating out of other pt's (patient's) rooms .has also attempted to go out of main entrance doors stating that I am going to my daughters (daughter's) house . Medical record review of the Order Summary Report documented, .Wander guard at all times .Start Date .07/10/2019 . Observations in Resident #377's room on 7/11/19 at 2:17 PM revealed Resident #377 seated in a chair with a wanderguard on her left ankle. Interview with the ADON on 7/14/19 at 4:19 PM, in the Conference Room, the ADON was asked why Resident #377 had a wanderguard. The ADON stated, .she did attempt to exit building . 11. Observations at the Hall 4 West Exit door on 7/10/19 at 3:46 PM, revealed the Facilities Director had a wanderguard tester device in his hand and held it near the exit door. No alarm sounded. The Facilities Director held the testing device up to the door again and no alarm sounded. The Facilities Director tried the third time, and the alarm sounded. Interview with the Facilities Director at the Hall 4 West exit door on 7/10/19 at 3:50 PM, the Facilities Director stated, This (door alarm) should have went off . Observations of all facility exit doors on 7/11/19 beginning at 3:35 PM, revealed the Facilities Director used a handheld wanderguard device, for checking the wanderguard alarm system but the Hall 4 West door did not lock when approached on first 2 attempts (the door should have automatically locked and alarmed when approached with the wanderguard device). The Facilities Director stated, It's (alarm) working intermittently. The Facilities Director used a second wanderguard alarm device and the Hall 4 West door only locked or alarmed intermittently. The Facilities Director stated, .left lower door alarm is not working . The Facilities Director stated the West 4 Hall door had an area of the door that was not working, there was only a certain area that was working and this was why the door would lock and alarm intermittently. The Facilities Director was asked if the door was secure to protect residents from elopement. The Facilities Director stated, It's a 1 foot area in the center of the door that's not picking up the wander guard signal .sensors need adjusting . The Facilities Director stated, .(Hall 6) door stays locked all the time, and you put in a code to get out. The Facilities Director had a wanderguard testing device in his hand, entered the door code, opened the door 3 times, and no alarm sounded. The Facilities Director stated, This door .is not equipped with a working wanderguard sensor . Interview with the Interim Administrator on 7/10/19 at 2:10 PM, in the Conference Room, the Interim Administrator was asked if the area where the residents went out to smoke was in an enclosed courtyard. The Interim Administrator confirmed the courtyard was not secured and residents could leave the premises. Interview with the Interim Administrator on 7/11/19 at 4:27 PM, at the Hall 6 Exit door during wanderguard testing, the Interim Administrator stated, A wanderer could get out. Interview with the Interim Administrator and the Facilities Director during observations of all 8 facility exit doors on 7/11/19 beginning at 5:07 PM, the Facilities Director and the Interim Administrator confirmed 4 of 8 (Hall 6 door, Hall 3 Dining Room door, Hall 2 Dining Room door, and Hall 1 door) exit doors were not equipped with wanderguard device alarms and the wanderguard sensor for the Hall 4 West door was not functioning correctly. Observations at the Hall 4 West Hall door by the laundry room on 7/11/19 beginning at 8:10 PM, revealed the door was unlocked and unsecured. Interview with the Interim Administrator, DON, ADON, and the Facilities Director, on 7/12/19 at 11:04 AM, the Facilities Director stated, I thought the keypads were the first defense. We were checking the keypad not the wanderguard. I thought (wanderguard) was our last line of defense . Interview with the Maintenance Technician on 7/15/19 at 10:55 AM, in the Conference Room, the Maintenance Technician was asked what kind of checks he had been doing on the doors related to the wanderguards. The Maintenance Technician stated, I would just check to see if they couldn't stroll on out the door without pressing the keypad number. The Maintenance Technician was asked if all the doors were equipped for the wanderguards. The Maintenance Technician stated, 3 . The Maintenance Technician confirmed there were 4 exit doors in the facility that were not equipped with wanderguard alarms prior to 7/12/19 and the Hall 4 West door wanderguard sensor was not functioning correctly prior to 7/12/19. The Maintenance Technician confirmed he had not been routinely checking the doors for wanderguard functioning. Interview with the Interim Administrator and the Assistant Administrator on 7/15/19 at 11:50 AM, in the Conference Room, the Interim Administrator was asked if he had the measurements to the highway. Measurements provided and confirmed by the Interim Administrator on 7/15/19 at 11:50 AM revealed the facility was 156 feet from a heavily traveled 4 lane state highway. 12. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, required limited to extensive staff assistance with activities of daily living (ADLs), and was coded for current tobacco use and oxygen therapy. Medical record review of the Care Plan fo (TRUNCATED)

Based on the Interim Administrator's Contract, Director of Nursing Job Description, medical record review, observation, and interview, the Interim Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to ensure the residents that smoked had adequate supervision, and failed to provide oversight and training of staff to ensure the security devices for the exit doors were operational and the exit codes to the doors remained secure. The Administration's failure placed Residents #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 in Immediate Jeopardy when staff did not assess, report, implement, evaluate or monitor for resident safety concerns for smoking and elopements. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist, and the Minimum Data Set (MDS) Coordinator #2, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited at scope and severity of Immediate Jeopardy for F657-K, F689-K, F835-K, F841-K, and F867-K. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An extended survey was conducted on 7/12/19 through 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F835-E for monitoring of effectiveness of the corrective actions. The findings include: The facility's Interim Administrator Contract dated 4/12/19 documented, .This Agreement shall be governed by and construed in accordance with the laws of the State of Tennessee .The Contractor agrees to .Oversees all activities of the care center in accordance with established policies and federal and state guidelines .Develop strategic plans for profitability and accountability for all operations and programs .Administer, direct and coordinate the business .Recommend and lead changes to improve the care center .Maintain a state administrator license .Create functional strategies and specific objectives for the care center and develop budgets/policies/procedures to support the functional infrastructure .Implement Administrator-in-Training Program . The facility's Director of Nursing Job Description dated 6/17/19 documented, .Under the direction of the Administrator, the DON has 24-hour responsibility for the effective implementation of the philosophy, goals, policies, and procedures .The DON has authority to make decisions .in the areas of patient care .Demonstrated leadership ability and potential managerial competency .Evidence of this includes, but is not limited to .ability to confront/resolve issues, ability to motivate others, ability to plan, organize, and direct the activities of others .Assist the Administrator in development, implementation and evaluation of on-going service programs that assure quality nursing and resident care programs consistent with health system mission .Evaluates on-going programs as assigned by Administrator .Monitors/maintains care center compliance with regulatory, accrediting and health system policy for resident services, and environmental and personnel safety .and/or universal precautions procedures as evidenced by PI (Performance Improvement) reports, incident follow-ups, staff meeting minutes and direct observation by Administrator .Oversees Care Center PI program which monitors and evaluates critical aspects of care .Accurately identifies real/potential problems affecting the services and implements solutions with follow-through and communications . ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards . Interview with the DON on 7/10/19 at 9:41 AM, in the Conference Room, the DON was asked if the residents knew the security codes to the exit doors and if residents could go out freely at anytime. The DON stated, Yes. Interview with the Interim Administrator, DON, ADON, MDS Coordinator #1 on 7/10/19 at 1:33 PM, in the Conference Room, the Interim Administrator was asked if they had identified problems with smoking at the facility. The Interim Administrator stated, We talked about smoking .June .that's when we formally as a group said, 'guys we need to address this issue' .talked about a supervised schedule . The Interim Administrator was asked if a supervised schedule had been implemented. The Interim Administrator stated, Not yet. The Administrator was asked if the residents were allowed to have their smoking materials, including lighters, in their possession, and allowed to go out unsupervised. The Interim Administrator stated, That's correct . The Interim Administrator confirmed the Hall 6 Smoking Porch opened to a Courtyard that was not secure or enclosed. Interview with the Interim Administrator on 7/11/19 at 4:27 PM, at the Hall 6 exit door during wander guard testing, the Interim Administrator stated, A wanderer could get out. The Interim Administrator was unable to state how long the 5 of 8 wanderguard door alarm devices had not been functioning. Interview with the Interim Administrator and the Assistant Administrator on 7/14/19 at 9:15 AM, in the Conference Room, the Interim Administrator was asked when he became aware that residents were smoking unsupervised. The Interim Administrator stated, .This is really something pretty serious .around the middle of the month of (MONTH) . The Interim Administrator stated, .we would be periodically walking out, and we would say wait a minute. There is nobody out here with these (residents) .I had been working with .the consultant .one of the things she said we need to be jumping on . The Interim Administrator was asked about residents having lighters in their possession in their rooms when they received oxygen therapy. The Interim Administrator stated, .just learning they had lighters, oxygen or not .I don't have this documented but I sat out with (Named Resident #88 and #22), and said I understand you have lighters, and we can't let you have those . Administration failed to provide oversight of staff when they failed to ensure a safe and consistent smoking regimen for residents which resulted in IJ for Resident #22, #30, #88, #102, and #180. The Administration failed to ensure staff maintained the confidential codes to the secure exit doors, which allowed residents to exit the building unsupervised. Administration failed to ensure the safety of residents with elopement risk, by not ensuring the wanderguard security devices on the exit doors were operational which placed Resident #2,#12, #13, #18, #38, #70, and #377 in IJ. Refer to F657 and F689. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The Social Service staff have called and reached all but five (5) families/representatives as of 7/14/19 and informed them of the new Smoking and Door Code changes; those who were not reached were left messages and the facility will continue to reach out to all families until all have been properly informed. In addition to personal contact with families, the facility has posted a notice on each outside door, outlining the process for gaining entry into the building. As an additional communication effort the facility has mailed a letter with the same details, officially notifying all family members of the facility's plan to become a Smoke Free Campus. Those letters will be mailed to each responsible party on 7/15/19. The surveyors reviewed resident charts to verify the calls were documented. the surveyors observed the Social Service staff calling the families to update the famlies on the new smoking and Door Code changes. 4. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 A.M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of the Medical Director's Agreement Contract, policy review, medical record review, observation, and interview, the Medical Director failed to ensure resident care policies were developed and implemented to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective plan to assure the residents' environment was safe and that vulnerable residents were adequately supervised. The Medical Director failed to identify issues and concerns in the facility related to smoking safety and elopement risk, which resulted in Immediate Jeopardy (IJ) for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 when staff failed to assess, report, implement, evaluate or monitor for resident safety concerns related to smoking and elopements. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist, and Minimum Data Set (MDS) Coordinator #2, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited a scope and severity of Immediate Jeopardy for F657-K, F-689-K, F835-K, F841-K, and F867-K. The extended survey was conducted on 7/12/19 through 7/15/19. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F 841-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The Medical Director's Professional Services Agreement Contract signed 7/24/09 by the Medical Director, documented, .Overall coordination and execution of medical care .Assisting in developing procedures .Participating in establishing policies, procedures and guidelines designed to assure the provision of adequate, comprehensive services .Participating in the resident care management system .Participating in the Centers' inservice education program .Establishing with other health care professionals, policies designed to assure the governing body that all health care professionals practice within the scope .Providing consultation to the Centers' Administrator, Director of Nurses, and Social Services regarding the Centers' ability to meet the psychosocial, medical and physical needs of the residents .Advising the Administrator about the adequacy and appropriateness of the Centers scope of services for residents, medical equipment, and professional support staff .Helping to assure a safe and sanitary environment for residents and personnel .reviewing and evaluating occurrence reports .Identifying hazards to health and safety .Making relevant recommendations to the Administrator .Monitoring and evaluating quality and appropriateness of medical services as an integral part of the overall quality assessment and improvement program .Serving on committees . 2. Telephone interview with the Medical Director on 7/15/19 at 8:18 AM, the Medical Director was asked how he was involved in resident management. The Medical Director stated, I am the attending. That allows me to be directly involved with their care and planning. The Medical Director was asked if he had provided consultation to the facility's Administration staff regarding the facility's ability to meet the needs of the residents. The Medical Director stated, Yes, I do that on daily and weekly basis by reviewing conditions, looking at their needs, if we are able to meet their needs. The Medical Director was asked if he was involved in the implementation of smoking policies when the 2 residents (Resident #88 and #102) were grandfathered in to smoke. The Medical Director stated, No . The Medical Director was asked if he reviewed and evaluated occurrence reports. The Medical Director stated, once a week .I review them. The Medical Director was asked if he had talked with Administration about unsupervised smoking and Resident #102's burn incident. The Medical Director stated, I honestly didn't remember it .I'm sure I signed the incident report .burn on skin and clothing .That would be normal process. The Medical Director was asked if he was aware residents were allowed to keep lighters and cigarettes in their rooms while they received oxygen. The Medical Director stated, That is not good .That is very risky with oxygen involved. I don't think that was a good idea. The Medical Director was asked if unsupervised smoking was appropriate. The Medical Director stated, .It would make sense to supervise them. The Medical Director was asked if he was aware residents were going out the doors unsupervised with wanderguards on. The Medical Director stated, .that's interesting .maintenance definitely should be checking that system. The Medical Director was asked how he assured a safe environment for residents. The Medical Director stated, I think QA (Quality Assurance) meetings are key . The Medical Director was asked if he monitored and evaluated the quality and appropriateness of medical services as an integral part of the overall quality assessment and improvement program and how often he attended. The Medical Director stated, Monthly . 3. The Medical Director failed to ensure the residents received staff supervision for smoking and elopement risk, failed to assist the facility with the establishment, development, and implementation of safe smoking policies, and failed to ensure residents were not allowed to have lighters when oxygen was in use. The Medical Director failed to ensure vulnerable residents with wanderguards and elopement risks were protected from elopement accidents. Refer to F689. 4. The Medical Director failed to ensure Administration was responsible for the identification, development, and implementation of appropriate policies and procedures to maintain the highest practicable well-being of all residents. Refer to F835. 5. The Medical Director failed to ensure the Quality Assurance Performance Improvement Committee provided a safe environment for cognitively impaired residents with at risk behaviors related to smoking safety and elopement and that the residents were supervised and monitored to prevent accidents, which resulted in IJ for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377. Refer to F867. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 A.M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the 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 that a resident who is incontinent of bladder receives appropriate treatment and services for symptoms of a urinary tract infection for 1 of 2 (Resident #212) sampled residents reviewed with a urinary tract infection. The failure to treat serviand provide ces in a timely manner, resulted in actual harm when Resident #212 was admitted to the hospital with [REDACTED]. The findings included: 1. The facility's UTI Constitutional Criteria policy documented, .To provide parameters for UTI testing in long term care .Procedure: 1. Meeting constitutional criteria will determine testing of urine. Residents exhibiting two or more of the following symptoms meet criteria for UTI. A. Fever 1. defined as single oral temperature > 100 degrees (F); or 2. Repeated oral temperatures > 99.5 degrees F .3. Single temperature > 2 degrees over baseline .B. Leukocytosis .C. Acute Change in Mental Status .D. Acute Functional Decline . 2. Medical record review revealed Resident #212 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment, and occasionally incontinent of urine. A care plan dated 2/3/16 revealed Resident #212 had an Activity of Daily Living (ADL) deficit with interventions to include resident requires extensive assistance by 1 staff member required for toileting. A nurses note dated 5/13/16 at 16:22 PM documented, .T (temperature) .102.4 at 4:15 PM .Tylenol 325 (milligrams (mg)) 2 tabs (tablets) given . The Lincoln/Donalson & Skilled Care Center Routine Standing Orders documented, .Mild Pain or Increased Temp .[MEDICATION NAME] 650 mg PO (by mouth) .q (every) 4 h (hour) . A physician's orders [REDACTED].send to (named emergency room ) for evaluation and treatment . A nurses note dated 5/16/16 at 1:26 AM, documented, .Resident running a temperature beginning on 5/13/16 at 4:00 PM 102.4 Tylenol given and rechecked at 5:00 PM after receiving Tylenol 650 mg temp (temperature) at that time was 99.8 .on 5/14/16 temp at 7:30 PM was 102.1 Tylenol given and temp rechecked at 10:00 PM 98.0 .on 5/15/16 at 5:45 PM temp 102.4 Tylenol given and temp rechecked at 7:50 PM 98.5. Spoke with (named daughter) at 8:15 PM about increased temp at night she stated that her mother had a history of [REDACTED]. order and I assured her that I would fax the MD (medical doctor). Granddaughter here .wanting to speak about the condition of her grand mother and the increased temp at night stated to the nurse that she would like to have her checked out and to go to (named hospital) where they are aware of history at that time (named physician) was notified of this concern and order was given to send resident to (named hospital) resident exited facility with grand daughter at 9:15 PM . A hospital .BACTERIOLOGY report dated 5/17/16 documented, .coll (collected) .5/15/16 .colony count > (greater than) 100,000 .organism .ESCHERICHIA COLI . A hospital History and Physical Note dated 5/16/16 documented, .has been running a high fever send (since) Friday .Temperature as high as 102 (degrees) .Assessment .Acute urinary tract infection .PLAN .admit patient to the medical ward .start .[MEDICATION NAME] 1 g (gram) IV (intravenously) daily . 3. In an interview with Licensed Practical Nurse (LPN) #2, 3, and 4 on 5/25/16 at 5:25 PM, at the South hall nurses station, LPN #2, 3, and 4 were asked when should a physician be notified about a resident with an elevated temperature. LPN #2 stated, If a resident runs a fever we have standing orders to give them Tylenol and then we recheck it in 4 hours .if they have another fever after that we call the doctor . LPN #3 and 4 confirmed LPN #2's statement. In an interview with the Director of Nursing (DON) on 5/25/16 at 5:39 PM, in the DON office, the DON was asked about the nurses notes dated 5/13/16 and 5/16/16 that documented an elevated temperature for Resident #212. The DON stated, We were aware of the situation .the nurse should have notified the physician and the family about the fever . In an interview with RN #1 on 5/25/16 at 6:02 PM, in the DON office, RN #1 stated, The doctor had called me about what was going on with Resident #212 and wanted to know why he wasn't notified about the elevated temps and I explained to him what had happened and that the nurses should have let him know . Interview with the DON on 5/26/16 at 8:05 AM, in the Donaldson geri psych conference room, the DON was asked if she had been able to find a policy on physician notification. The DON stated, .there is not a specific parameter for vital signs .for notifying doctor .we expect nurses to use their judgement . In a telephone Interview with LPN #5 on 5/26/16 at 11:27 AM, LPN #5 was asked if she had written the nurses note dated 5/16/16 about the elevated temperatures for Resident #212. LPN #5 stated, Yes . LPN #5 was asked if the note was a summary of the events leading up to the hospitalization of Resident #212. LPN #5 stated, it was a summary . LPN #5 was asked if she knew that Resident #212 had a temperature of 102.4 on 5/13/16. LPN #5 stated, Yes, I read it on the 24 hour report. LPN #5 was asked what type of assessment she performed on 5/14/15 at 5:25 AM, when she discovered Resident #212 had a temperature of 101.1. LPN #5 stated, I don't recall doing an assessment . LPN #5 was asked if she checked Resident #212's temperature on 5/14/15 at 7:30 PM. LPN #5 stated, No, the CNA (Certified Nurse Assistant) took it and reported it to me. LPN #5 was asked if she performed an assessment at that time. LPN #5 stated, No, I gave the Tylenol. We have standing orders for mild pain and increased temp they are the Tylenol 650 mg. LPN #5 was asked if she reported any of the temperature elevations for Resident #212 to the physician. LPN #5 stated, No, I gave the Tylenol .sometimes those rooms are hot and they have a whole lot of covers on them. If they are not coughing or sneezing, I just monitor them for further temp .it might be a myth .people run high temps at night .in my thinking I gave the Tylenol, they were relieved and she didn't complain about anything .I just thought like that . LPN #5 was asked if she should have called the physician about the elevated temperatures. LPN #5 stated, Ma'am, I don't know .that Sunday, the resident's granddaughter came to me at my cart around 9 PM and was concerned about Resident #212 and wanted the doctor called. I called Physician #1 and told him about the temps and the history of UTIs. The granddaughter talked to him and he told her he was not aware of the elevated temps. In a telephone interview with Resident #212's granddaughter on 5/26/16 at 2:00 PM, the granddaughter was asked about the events on the weekend of 5/14/16. The granddaughter stated, I am a hospitalist at (named hospital), so my aunts had asked me to check on her .she had run fever of 101 and the nurse had given her Tylenol. I came in on Saturday morning .I said to the nurse in charge could we do a UA (urinalysis) or chest x-ray since she's been running a fever 24 hours. The nurse said no because they have had a cough/cold through the nursing home with several people running fevers. Sunday, I got a call that her temp was 102.5 so I went to the facility and spoke to the nurse and told her I wanted to take my grandmother to the hospital. The nurse looked back through the records and saw where she had been running the high temps and called Physician #1 sometime between 7 and 8 PM. I talked with him and he said he was shocked, that this was the first time he had heard about it. We (family) had noticed her urine had a foul odor on Thursday and her aide had mentioned her urine smelled really bad. I had asked the nurse, can you do a urinalysis here and she told me no. In a telephone interview with the Physician on 5/26/16 at 5:11 PM, by phone. The Physician was asked about the events on the weekend of 5/14/16 for Resident #212. The Physician stated, I received a call on Sunday from Resident #212's granddaughter who is apparently an NP (Nurse Practitioner) or Hospitalist that she was running a fever and her urine smelled foul, probably had a UTI. She wanted to take her to (named hospital) for the UTI. The Physician was asked if he was notified any time before Sunday about Resident #212's fever. The Physician stated, No, I wasn't. I did call back and spoke to the Director (of Nursing) and she told me that the nurse had not followed protocol .they should have called when she began running fever .if I had known about it, I would have ordered the UA and a CBC (complete blood count) .you know she's an elderly patient with a fever .I could have treated it .I would have liked to have had a call . The facility failed to treat and provide services for symptoms of a urinary tract infection in a timely manner for Resident #212, which resulted in actual harm when Resident #212 was admitted to the hospital with [REDACTED].

Based on The National Pressure Ulcer Advisory Panel .Prevention and treatment of [REDACTED].#18) sampled residents, who was admitted with no pressure ulcers from developing Deep Tissue Injury (DTI) and a Stage 2 pressure ulcer. The facility's failure to put preventive measures in place prior to the development of a DTI to the left buttock, failure to timely identify, accurately assess, and consistently treat the wound from 4/4/16 to 4/21/16, and failure to update the plan of care resulted in actual harm to Resident #18. The findings included: 1. The The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (ED). Cambridge Media: Osborne Park, Western Australia; 2014 page 16 documented, .1.2 Document the findings of all comprehensive skin assessments .2 .Ongoing assessment of the skin is necessary to detect early signs of pressure damage, especially over bony prominences . 2. Review of the facility's Wound Care Management policy documented, .A licensed nurse will complete a skin assessment at the time of admission .Procedure .3. All residents will be assessed weekly .6. Each wound will be assessed and a wound protocol (see attached) will be individualized according to each resident's specific needs in collaboration with the primary care physician. 7. Wound care protocol may be adjusted if the wound shows deterioration or improvement . The attached WOUND PROTOCOL documented, .PATIENT admitted WITH STAGE II WOUND (admitted WITH OR ACQUIRED): Air mattress or concave mattress . 3. Medical record review revealed Resident #18 was readmitted to the Lincoln Donalson Care Center facility on 3/25/16 with [DIAGNOSES REDACTED]. Resident #18 was readmitted to the Lincoln Donalson Care Center without pressure sores. Resident #18 was admitted to hospice services on 4/4/16. The Nursing Admission Summary dated 4/4/16 documented, .Buttocks red with some excoriation . The HOSPICE INITIAL NURSING ASSESSMENT dated 4/4/16 documented, .(bilateral) buttocks Red-blanchable excoriated . The physician's orders [REDACTED].[MEDICATION NAME] to affected area TID (three times each day) PRN . The Medication Administration Record dated 4/4/16 documented, .[MEDICATION NAME] Cream (Topically) TID (three times each day) PRN (as needed) see Tx (treatment) Sheet . There was no documentation on the treatment record the treatments had been administered to the affected buttocks area. Care plan dated 4/21/16 documented, The resident has potential for pressure ulcer development r/t (related to) decreased mobility .INTERVENTIONS/TASKS 4/4/16 [MEDICATION NAME] to affected area TID PRN 4/25/16 Air mattress to bed .Administer treatments as ordered and monitor for effectiveness . The EVALUATION OF WOUND AVOIDABILITY assessment dated [DATE] documented the resident's left buttock pressure ulcer was Deep tissue injury and the right buttock was a Stage II . The assessment documented the wound was unavoidable related to .Pt is Hospice .Chronic Bowel Incontinence .[MEDICAL CONDITION] . The assessment documented, .Resident is receiving Routine Preventative Care Daily .Care plan appropriate .Care plan implemented consistently . There was no documentation the care plan was revised to reflect that Resident #18 had actual pressure ulcers. There was no documentation the [MEDICATION NAME] was applied prior to the development of the pressure ulcers The E-Z GRAPH WOUND ASSESSMENT WORKSHEET dated 4/27/16 documented the following pressure ulcers: .both inner buttocks (and) sacrum Deep tissue injury . and on the left buttock, .(with) superficial open area . and the right buttock, .Stage II 2.25 (centimeters) x (by)1.75 (centimeters) . In an interview with Minimum Data Set (MDS) Coordinator #2, on 5/25/16 at 9:50 AM, in the Lincoln Donalson Care Center conference room, MDS Coordinator #2 was asked about Resident #18's wounds, if the excoriation healed or later developed into the Deep Tissue Injury (DTI) and Stage 2 pressure ulcers. MDS Coordinator #2 confirmed, You were right it did . develop into the pressure ulcers. In an interview with the Certified Wound Ostomy Continence Nurse (CWOCN) on 5/26/16 at 9:47 AM, in the Lincoln Donalson Care Center conference room, the CWOCN was asked if she would expect a back up system to be in place to ensure interventions are being done and done correctly. The CWOCN nodded her head affirmative. In an interview with the MDS Coordinator #2 on 5/26/16 at 3:05 PM, at the 400 hall nurses' station, MDS Coordinator #2 was asked if there was any documentation that the [MEDICATION NAME] had been applied to Resident #18's buttocks between 4/4/16 and 4/25/16, MDS Coordinator #2 stated, There's not anything done for those 2 weeks . In an interview with MDS Coordinator #2, on 5/25/16 at 9:50 AM, in the conference room, when asked about Resident #18's wounds and if the excoriation never cleared up or developed into the DTI and Stage 2 pressure ulcers. MDS Coordinator #2 confirmed, You were right it did . develop into the pressure ulcers. In an interview with MDS Coordinator #2 on 5/26/16 at 3:05 PM, at the 400 hall nurses' station, when asked if there was any documentation that the [MEDICATION NAME] had been applied to Resident #18's buttocks between 4/4/16 and 4/25/16, MDS Coordinator #2 stated, There's not anything done for those 2 weeks . Observations on 5/26/16 at 8:23 AM revealed pressure ulcers to the right and left buttock. The E-Z GRAPH WOUND ASSESSMENT WORKSHEET dated 5/26/16 documented, Left Buttock had 2 stage II pressure ulcers measuring 2 cm x 1 cm x shallow and the other measured 0.4 cm x 0.3 cm. The Right Buttock had 3 areas; #1 was a Non-stagable area that measured 4.6 cm x 2.8 cm, #2 was a blister that measured 1.1 cm x 1 cm and #3 was a red area that was 1.5 cm x 2. 5 cm. The facility's failure to put preventive measures in place prior to the development of a DTI to the left buttock, failure to timely identify, accurately assess, and consistently treat the wound from 4/4/16 to 4/21/16, and failure to update the plan of care resulted in actual harm to Resident #18.

Based on facility policy review, medical record review and interview, the facility failed to develop a comprehensive care plan for urinary incontinence and for care and services to prevent UTIs for 1 of 24 (Resident #2) sampled residents of the 41 included in the Stage 2 review. The failure to develop and implement a written plan of care to prevent UTIs resulted in Resident #212 being hospitalized with a UTI. The findings included: 1. The facility's UTI Constitutional Criteria policy documented, .To provide parameters for UTI testing in long term care .Procedure: 1. Meeting constitutional criteria will determine testing of urine. Residents exhibiting two or more of the following symptoms meet criteria for UTI. A. Fever 1. defined as single oral temperature > 100 degrees (F); or 2. Repeated oral temperatures > 99.5 degrees F .3. Single temperature > 2 degrees over baseline .B. Leukocytosis .C. Acute Change in Mental Status .D. Acute Functional Decline . 2. Medical record review revealed Resident #212 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment, and occasionally incontinent of urine. The 4/20/16 MDS documented, Section G the resident required extensive assistance of 1 for toileting; Section H documented the resident was occasionally incontinent and was not on a toileting program; and Section N documented the resident was on a diuretic. Review of the MDS dated [DATE] revealed the Care Area Assessment (CAA) Summary triggered for the care area of Urinary Incontinence and Indwelling Catheter. The care plan dated 2/3/16 revealed Resident #212 had an Activity of Daily Living (ADL) deficit for Toileting with interventions that included the resident requires extensive assistance by 1 staff member required for toileting and personal hygiene. The care plan documented, .Monitor/document/report PRN ay changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function . There was no documentation the resident's care plan included care and services to address the triggered .Urinary Incontinence . or to prevent UTIs. A nurse's note dated 5/13/16 at 16:22 PM documented, .T (temperature) .102.4 at 4:15 PM .Tylenol 325 (milligrams (mg)) 2 tabs (tablets) given . A physician's orders [REDACTED].send to (named emergency room ) for evaluation and treatment . A summarization nurses note dated 5/16/16 at 1:26 AM, documented, .Resident running a temperature beginning on 5/13/16 at 4:00 PM 102.4 Tylenol given and rechecked at 5:00 PM after receiving Tylenol 650 mg temp (temperature) at that time was 99.8 .on 5/14/16 temp at 7:30 PM was 102.1 Tylenol given and temp rechecked at 10:00 PM 98.0 .on 5/15/16 at 5:45 PM temp 102.4 Tylenol given and temp rechecked at 7:50 PM 98.5. Spoke with (named daughter) at 8:15 PM about increased temp at night she stated that her mother had a history of [REDACTED]. order and I assured her that I would fax the MD (medical doctor). Granddaughter here .wanting to speak about the condition of her grandmother and the increased temp at night stated to the nurse that she would like to have her checked out and to go to (named hospital) where they are aware of history at that time (named physician) was notified of this concern and order was given to send resident to (named hospital) resident exited facility with granddaughter at 9:15 PM . A hospital .BACTERIOLOGY report dated 5/17/16 documented, .coll (collected) .5/15/16 .colony count > (greater than) 100,000 .organism .ESCHERICHIA COLI . A hospital History and Physical Note dated 5/16/16 documented, .has been running a high fever send (since) Friday .Temperature as high as 102 (degrees) .Assessment .Acute urinary tract infection .PLAN .admit patient to the medical ward .start .[MEDICATION NAME] 1 g (gram) IV (intravenously) daily . 3. In an interview with the Director of Nursing (DON) on 5/25/16 at 5:39 PM, in the DON office, the DON was asked about the nurses notes dated 5/13/16 and 5/16/16 that documented an elevated temperature for Resident #212. The DON stated, We were aware of the situation .the nurse should have notified the physician and the family about the fever . In a telephone interview with LPN #5 on 5/26/16 at 11:27 AM, LPN #5 was asked if she had written the nurses note dated 5/16/16 about the elevated temperatures for Resident #212. LPN #5 stated, Yes . LPN #5 was asked if the note was a summary of the events leading up to the hospitalization of Resident #212. LPN #5 stated, it was a summary . LPN #5 was asked if she knew that Resident #212 had a temperature of 102.4 on 5/13/16. LPN #5 stated, Yes, I read it on the 24 hour report. LPN #5 was asked what type of assessment she performed on 5/14/15 at 5:25 AM, when she discovered Resident #212 had a temperature of 101.1. LPN #5 stated, I don't recall doing an assessment . In a telephone interview with Resident #212's granddaughter on 5/26/16 at 2:00 PM, the granddaughter was asked about the events on the weekend of 5/14/16. The granddaughter stated, I am a hospitalist at (named hospital), so my aunts had asked me to check on her .she had run fever of 101 and the nurse had given her Tylenol. I came in on Saturday morning .I said to the nurse in charge could we do a UA (urinalysis) or chest x-ray since she's been running a fever 24 hours. The nurse said no because they have had a cough/cold through the nursing home with several people running fevers. Sunday, I got a call that her temp was 102.5 so I went to the facility and spoke to the nurse and told her I wanted to take my grandmother to the hospital. The nurse looked back through the records and saw where she had been running the high temps and called Physician #1 sometime between 7 and 8 PM. I talked with him and he said he was shocked, that this was the first time he had heard about it. We (family) had noticed her urine had a foul odor on Thursday and her aide had mentioned her urine smelled really bad. I had asked the nurse, can you do a urinalysis here and she told me no. The facility failed to provide a comprehensive plan of care that addressed incontinence and the prevention of UTIs and failed to develop a plan of care to provide timely services for symptoms of a urinary tract infection for Resident #212, which resulted in actual harm when Resident #212 was admitted to the hospital with [REDACTED].

Based on medical record review and interview, the facility failed to ensure staff notified the physician timely for a resident with a fever for 1 of 2 (Resident #212) sampled residents reviewed with a urinary tract infection. The failure to notify the physician for 2 days resulted in actual harm when Resident #212 was admitted to the hospital with [REDACTED]. The findings included: 1. Medical record review revealed Resident #212 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment, and occasionally incontinent of urine. A care plan dated 2/3/16 revealed Resident #212 had an Activity of Daily Living (ADL) deficit with interventions to include resident requires extensive assistance by 1 staff member required for toileting. The Lincoln/Donalson & Skilled Care Center Routine Standing Orders documented, .Mild Pain or Increased Temp (temperature) . [MEDICATION NAME] 650 mg (milligrams) PO (by mouth) .q (every) 4 h (hour) . A nurses note dated 5/13/16 at 4:22 PM documented, .T (temperature) .102.4 at 4:15 PM .Tylenol 325 (milligrams) 2 tabs (tablets) given . A physician's orders [REDACTED].send to (named emergency room ) for evaluation and treatment . A nurses note dated 5/16/16 at 1:26 AM documented, .Resident running a temperature beginning on 5/13/16 at 4:00 PM 102.4 Tylenol given and rechecked at 5:00 PM after receiving Tylenol 650 mg temp at that time was 99.8 .on 5/14/16 temp at 7:30 PM was 102.1 Tylenol given and temp rechecked at 10:00 PM 98.0 .on 5/15/16 at 5:45 PM temp 102.4 Tylenol given and temp rechecked at 7:50 PM 98.5. Spoke with (named daughter) at 8:15 PM about increased temp at night she stated that her mother had a history of [REDACTED]. order and I assured her that I would fax the MD (medical doctor). Grand daughter here .wanting to speak about the condition of her grand mother and the increased temp at night stated to the nurse that she would like to have her checked out and to go to (named hospital) where they are aware of history at that time (named physician) was notified of this concern and order was given to send resident to (named hospital) resident exited facility with grand daughter at 9:15 PM . A hospital .BACTERIOLOGY report dated 5/17/16 documented, .coll (collected) .5/15/16 .colony count > (greater than) 100,000 .organism .ESCHERICHIA COLI . The hospital History and Physical Note dated 5/16/16 documented, .has been running a high fever send (since) Friday .Temperature as high as 102 (degrees) .Assessment .Acute urinary tract infection .PLAN .admit patient to the medical ward .start .[MEDICATION NAME] 1 g (gram) IV (intravenously) daily . The hospital Discharge Summary dated 5/17/16 documented, .Admitting [DIAGNOSES REDACTED]. 2. In an interview with Licensed Practical Nurse (LPN) #2, 3, and 4 on 5/25/16 at 5:25 PM, at the South hall nurses station, LPN #2, 3, and 4 were asked when should a physician be notified about a resident with an elevated temperature. LPN #2 stated, If a resident runs a fever we have standing orders to give them Tylenol and then we recheck it in 4 hours .if they have another fever after that we call the doctor . LPN #3 and 4 confirmed LPN #2's statement. In an interview with the Director of Nursing (DON) on 5/25/16 at 5:39 PM, in the DON office, the DON was asked about the nurses notes dated 5/13/16 and 5/16/16 that documented an elevated temperature for Resident #212. The DON stated, We were aware of the situation .the nurse should have notified the physician and the family about the fever . In an interview with RN #1 on 5/25/16 at 6:02 PM, in the DON office, RN #1 stated, The doctor had called me about what was going on with (Resident #212) and wanted to know why he wasn't notified about the elevated temps and I explained to him what had happened and that the nurses should have let him know . Interview with the DON on 5/26/16 at 8:05 AM, in the Donaldson geri psych conference room, the DON was asked if she had been able to find a policy on physician notification. The DON stated, .there is not a specific parameter for vital signs .for notifying doctor .we expect nurses to use their judgement . In a telephone Interview with LPN #5 on 5/26/16 at 11:27 AM, LPN #5 was asked if she had written the nurses note dated 5/16/16 about the elevated temperatures for Resident #212. LPN #5 stated, Yes . LPN #5 was asked if the note was a summary of the events leading up to the hospitalization of Resident #212. LPN #5 stated, it was a summary . LPN #5 was asked if she knew that Resident #212 had a temperature of 102.4 on 5/13/16. LPN #5 stated, Yes, I read it on the 24 hour report. LPN #5 was asked what type of assessment she performed on 5/14/15 at 5:25 AM, when she discovered Resident #212 had a temperature of 101.1. LPN #5 stated, I don't recall doing an assessment . LPN #5 was asked if she checked Resident #212's temperature on 5/14/15 at 7:30 PM. LPN #5 stated, No, the CNA (Certified Nurse Assistant) took it and reported it to me. LPN #5 was asked if she performed an assessment at that time. LPN #5 stated, No, I gave the Tylenol. We have standing orders for mild pain and increased temp they are the Tylenol 650 mg. LPN #5 was asked if she reported any of the temperature elevations for Resident #212 to the physician. LPN #5 stated, No, I gave the Tylenol .sometimes those rooms are hot and they have a whole lot of covers on them. If they are not coughing or sneezing, I just monitor them for further temp .it might be a myth .people run high temps at night .in my thinking I gave the Tylenol, they were relieved and she didn't complain about anything .I just thought like that . LPN #5 was asked if she should have called the physician about the elevated temperatures. LPN #5 stated, Ma'am, I don't know .that Sunday, the resident's granddaughter came to me at my cart around 9 PM and was concerned about (Resident #212) and wanted the doctor called. I called (Resident #212's) Physician and told him about the temps and the history of UTIs. The granddaughter talked to him and he told her he was not aware of the elevated temps. In a telephone interview with Resident #212's granddaughter on 5/26/16 at 2:00 PM, the granddaughter was asked about the events on the weekend of 5/14/16. The granddaughter stated, I am a hospitalist at (named hospital), so my aunts had asked me to check on her .she had run fever of 101 and the nurse had given her Tylenol. I came in on Saturday morning .I said to the nurse in charge could we do a UA (urinalysis) or chest x-ray since she's been running a fever 24 hours. The nurse said no because they have had a cough/cold through the nursing home with several people running fevers. Sunday, I got a call that her temp was 102.5 so I went to the facility and spoke to the nurse and told her I wanted to take my grandmother to the hospital. The nurse looked back through the records and saw where she had been running the high temps and called the Physician sometime between 7 and 8 PM. I talked with him and he said he was shocked, that this was the first time he had heard about it. We (family) had noticed her urine had a foul odor on Thursday and her aide had mentioned her urine smelled really bad. I had asked the nurse, can you do a urinalysis here and she told me no. In a telephone interview with Resident #212's Physician on 5/26/16 at 5:11 PM, The Physician was asked about the events on the weekend of 5/14/16 for Resident #212. The Physician stated, I received a call on Sunday from (Resident #212's) granddaughter who is apparently a NP (Nurse Practitioner) or Hospitalist that she was running a fever and her urine smelled foul, probably had a UTI. She wanted to take her to (named hospital) for the UTI. The Physician was asked if he was notified any time before Sunday about Resident #212's fever. The Physician stated, No, I wasn't. I did call back and spoke to the Director (of Nursing) and she told me that the nurse had not followed protocol .they should have called when she began running fever .if I had known about it, I would have ordered the UA and a CBC (complete blood count) .you know she's an elderly patient with a fever .I could have treated it .I would have liked to have had a call . The facility was unable to provide a policy for physician notification. The facility failed to notify the physician when Resident #212 ran a fever over a two (2) day time period, and resulted in a delay of treatment and actual harm when Resident #212 was admitted to the hospital for an acute urinary tract infection.

Intakes: TN 697 Based on review of the "MED-PASS COMMON INSULINS" provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 13 nurses (Nurses #1, 2 and 12) administered medications without a significant medication error. Nurse #1 and 2 failed to administer insulin within the proper time frame related to meals for Random Resident (RR) #1 and RR #2. Nurse #12 failed to identify a resident by picture and administered medications to the wrong resident resulting in actual harm to Resident #28. The findings included: 1. Review of the facility's "Identification of Residents" policy documented, "POLICY: The Care Centers will provide a means to identify individual residents and record information that can be accessed as needed. PROCEDURE: 1. All ICF (intermediate care facility) residents are photographed on admission and on periodic basis as a means of identification..." 2. Medical record review for Resident #28 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes dated 9/4/11 at 9:25 PM documented, "Resident received wrong medications. Immediately called ER. (emergency room ) Physician...Received orders to transfer pt (patient) to (name of hospital) ER..." Review of the nurses notes dated 9/5/11 at 1:05 AM documented, "Resident admitted to (named hospital)." Review of the facility's investigation revealed Resident #28 and Resident #31 had the same first name and were living on the same hall on 9/4/11. Resident #31 was a recent admission to the hall. Nurse #12 was assisting Nurse #11 to finish the medication pass. Nurse #12 administered Resident #31's medications to Resident #28. Review of Resident #31's September, 2011 Medication Administration record (MAR) documented the following medications were administered to Resident #28 on 9/4/11: Aspirin (ASA) 325 milligrams (mg), [MEDICATION NAME] 0.2 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 10 mg, Sodium [MEDICATION NAME] 650 mg and [MEDICATION NAME] 0.25 mg. Review of Resident #28's physician's orders [REDACTED].#28. During a phone interview in the Director of Nursing office on 9/27/11 at 3:15 PM, Nurse #12 stated, "...I was not aware of another (first name of resident)..." The nurse failed to identify the resident according to the picture on the MAR and administered the medication to the wrong resident resulting in actual harm to Resident #28 when Resident #28 was admitted to the hospital intensive care unit for intensive monitoring. 3. Review of the "MED-PASS COMMON INSULINS: Pharmacokinetics, Compatability, and Properties" provided by the American Society of Consultant Pharmacists for typical dosing administration of insulin related to meals documented, "[MEDICATION NAME] ONSET (In hours, unless noted)... 15 minutes...TYPICAL DOSING/COMMENTS...5-(to) 10 minutes before meals..." 4. Review of the facility's "Medication Administration" policy documented, "...Fast Acting Insulin Administration...For residents receiving fast acting insulins, the following procedure will be followed based on type of insulin prescribed and administered... 2. Humalog 15 minutes before eating..." 5. Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (equals) 1U, 160-189 = 2U, 190-219 = 3U, 220-249 = 4U, 250-279 = 5U, 280-299 = 6U, >(greater than) 300 = 7U & CALL MD (medical doctor) ..." Observations in RR #1's room on 9/27/11 at beginning at 10:40 AM, revealed Nurse #2 administered Humalog 7 U Sub-Q to RR #1 at 10:50 AM. RR #1 took the first bite of his meal at 11:46 AM. The administration of the Humalog Insulin 56 minutes prior to his meal resulted in a significant medication error. Medical record review for RR #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].=5U, 210-229=6U, 230-249=7U, 250-269=8U, 270-289=9U, 290-309=10U, 310-329=11U, 330-349=12U, 350-369=13U, 370-389=14U, 390-400=15U, < (less than) 60 or > 400 CALL MD ..." Observations in RR #2's room on 9/27/11 at 11:15 AM, revealed Nurse #1 performed an accucheck with results of 215. Nurse #1 drew up the [MEDICATION NAME] 14 units as scheduled, then drew up the additional [MEDICATION NAME] 6 units per SSI coverage. Nurse #1 administered a total of 20 units of [MEDICATION NAME]to RR #2. RR #2 took the first bite of his lunch meal at 11:42 AM. The administration of the [MEDICATION NAME] Insulin 27 minutes prior to his meal resulted in a significant medication error. During an interview in the Minimum Data Set office on 9/28/11 at 10:50 AM, The Director of Nursing (DON) #1 was asked what she expected of the nurses regarding [MEDICATION NAME] Insulin and meal time. DON #1 stated, "...The residents have to eat within 15 minutes after receiving [MEDICATION NAME] Insulin ..."

Based on review of the "MED-PASS COMMON INSULINS" provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 13 nurses (Nurses #1, 2 and 12) administered medications without a significant medication error. Nurse #1 and 2 failed to administer insulin within the proper time frame related to meals for Random Resident (RR) #1 and RR #2. Nurse #12 failed to identify a resident by picture and administered medications to the wrong resident resulting in actual harm to Resident #28. The findings included: 1. Review of the facility's "Identification of Residents" policy documented, "POLICY: The Care Centers will provide a means to identify individual residents and record information that can be accessed as needed. PROCEDURE: 1. All ICF (intermediate care facility) residents are photographed on admission and on periodic basis as a means of identification..." 2. Medical record review for Resident #28 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes dated 9/4/11 at 9:25 PM documented, "Resident received wrong medications. Immediately called ER. (emergency room ) Physician...Received orders to transfer pt (patient) to (name of hospital) ER..." Review of the nurses notes dated 9/5/11 at 1:05 AM documented, "Resident admitted to (named hospital)." Review of the facility's investigation revealed Resident #28 and Resident #31 had the same first name and were living on the same hall on 9/4/11. Resident #31 was a recent admission to the hall. Nurse #12 was assisting Nurse #11 to finish the medication pass. Nurse #12 administered Resident #31's medications to Resident #28. Review of Resident #31's September, 2011 Medication Administration record (MAR) documented the following medications were administered to Resident #28 on 9/4/11: Aspirin (ASA) 325 milligrams (mg), [MEDICATION NAME] 0.2 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 10 mg, Sodium [MEDICATION NAME] 650 mg and [MEDICATION NAME] 0.25 mg. Review of Resident #28's physician's orders [REDACTED].#28. During a phone interview in the Director of Nursing office on 9/27/11 at 3:15 PM, Nurse #12 stated, "...I was not aware of another (first name of resident)..." The nurse failed to identify the resident according to the picture on the MAR and administered the medication to the wrong resident resulting in actual harm to Resident #28 when Resident #28 was admitted to the hospital intensive care unit for intensive monitoring. 3. Review of the "MED-PASS COMMON INSULINS: Pharmacokinetics, Compatability, and Properties" provided by the American Society of Consultant Pharmacists for typical dosing administration of insulin related to meals documented, "[MEDICATION NAME] ONSET (In hours, unless noted)... 15 minutes...TYPICAL DOSING/COMMENTS...5-(to) 10 minutes before meals..." 4. Review of the facility's "Medication Administration" policy documented, "...Fast Acting Insulin Administration...For residents receiving fast acting insulins, the following procedure will be followed based on type of insulin prescribed and administered... 2. Humalog 15 minutes before eating..." 5. Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (equals) 1U, 160-189 = 2U, 190-219 = 3U, 220-249 = 4U, 250-279 = 5U, 280-299 = 6U, >(greater than) 300 = 7U & CALL MD (medical doctor) ..." Observations in RR #1's room on 9/27/11 at beginning at 10:40 AM, revealed Nurse #2 administered Humalog 7 U Sub-Q to RR #1 at 10:50 AM. RR #1 took the first bite of his meal at 11:46 AM. The administration of the Humalog Insulin 56 minutes prior to his meal resulted in a significant medication error. Medical record review for RR #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].=5U, 210-229=6U, 230-249=7U, 250-269=8U, 270-289=9U, 290-309=10U, 310-329=11U, 330-349=12U, 350-369=13U, 370-389=14U, 390-400=15U, < (less than) 60 or > 400 CALL MD ..." Observations in RR #2's room on 9/27/11 at 11:15 AM, revealed Nurse #1 performed an accucheck with results of 215. Nurse #1 drew up the [MEDICATION NAME] 14 units as scheduled, then drew up the additional [MEDICATION NAME] 6 units per SSI coverage. Nurse #1 administered a total of 20 units of [MEDICATION NAME]to RR #2. RR #2 took the first bite of his lunch meal at 11:42 AM. The administration of the [MEDICATION NAME] Insulin 27 minutes prior to his meal resulted in a significant medication error. During an interview in the Minimum Data Set office on 9/28/11 at 10:50 AM, The Director of Nursing (DON) #1 was asked what she expected of the nurses regarding [MEDICATION NAME] Insulin and meal time. DON #1 stated, "...The residents have to eat within 15 minutes after receiving [MEDICATION NAME] Insulin ..."