Every finding on record at Edwardsville Care and Rehab

Based on observation, record review, and interview, the facility failed to ensure dietary staff appropriately stored, labeled, and dated foods after the original storage container was opened. Findings included:- During the initial tour of the facility kitchen on 08/03/2026 at 08:13 AM, observation revealed the stand-alone refrigerator had a gallon jug of 2% milk that was half full did not have an open date on it. A half-gallon jug of chocolate milk was opened and did not have an open date on it. In the walk-in refrigerator, there were five-pound containers of ham salad, pasta salad, and potato salad that had been opened but lacked an open date. There was a gallon container of creamy Italian dressing that had been opened but lacked an open date. The dry storage area had an opened two-pound bag of powdered sugar that was opened and not in a sealed bag, which lacked an open date. All these food items were removed by the kitchen staff. On 08/03/2026 at 08:25 PM, Dietary CC stated that all foods should be labeled open or use by date and be stored in a sealed container or bag.On 08/05/2026 at 10:55 AM, Dietary BB stated that dietary staff should be labeling all foods with an open or use by as well as in a sealed container or bag.A policy for food storage was requested by the facility on 08/05/2026 but was not provided.

Based on interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter1 (October 1-December 31/2025), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30, 2025), and Quarter 4 (July 1-September 30, 2025) indicated the facility had excessively low weekend nurse staffing. Review of the facility's weekend nursing schedules and working hours for the above Quarters revealed the facility had adequate staffing. On 08/18/25 at 08:26 AM, Administrative Staff A stated the administrator and corporate staff were responsible for submitting the PBJ. The facility's PBJ Policy, revised 10/2025, documented the facility would submit PBJ data in a uniform format to CMS, including staffing community, agency, and contact staff.

Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). Findings Included:- On 04/06/2026 at 11:51 AM, Maintenance Supervisor (MS) U verified the facility had no water management program. MS U stated he tested water temperatures daily in the laundry room and resident rooms but did not document them. MS U stated he had the testing material for Legionella but had not used it. Maintenance Staff U stated he was unaware of how to establish a water management program but would get with the facility's corporation to find out. On 04/06/2026 at 12:00 PM, Administrative Staff A stated he was unaware the facility was required to develop a water management program and verified they did not have one.The facility's Water Management, Legionella Testing Policy, revised 03/2026, documented the facility would handle and maintain its water supply in accordance with recommendations of the Centers for Disease Control (CDC), the Healthcare Infection Control Practices Advisory Committee, and the Federal Drug Administration (FDA) guidelines approaches to controlling waterborne microorganisms (tiny living things). The policy documented the facility would conduct Legionella testing, complete the review of the water system annually, and document the infection control committee minutes and the findings. Cultures may be recommended based upon potential outbreaks. The policy documented that hot water distribution systems serving resident care areas would be continuously recirculated.

Based on record review, interview, and observation, the facility failed to provide care for Resident (R) 4 and R1 in a manner that protected and promoted their dignity. Findings included:- On 08/04/2026 at 07:32 AM, observation in the commons area revealed Licensed Nurse (LN) G pulled R4's shirt up on his left arm and cleansed the area with an alcohol wipe and administered an insulin injection subcutaneous (applied under the skin), in his right upper arm, with two surveyors, multiple facility employees and numerous other residents in full view of the procedure from the four halls and dining room area. On 08/04/2026 at 07:40 AM, observation in the commons area revealed LN G pulled R1's shirt up on his left arm and cleansed with an alcohol wipe, and administered an insulin injection subcutaneous, in his right upper arm in full view of two Surveyors, multiple facility employees, and numerous other residents. On 08/05/2026 at 08:10 AM, Administrative Nurse D verified LN G should not administer insulin injections in the public area; they should take the residents to their rooms or a private area. The facility's Respect and Dignity; Right to Personal Property, policy, dated August 2026, documented resident have the right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishings, and clothing, as space permits unless to do so would infringe upon the rights and safety of other residents.

Based on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)47's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications. Findings include:- R47's Electronic Health Record (EHR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, irrational fear), restlessness, and agitation. R47's Quarterly Minimum Data Set (MDS) dated [DATE], recorded R47 had moderately impaired cognition. The MDS recorded that she required staff assistance with all activities of daily living (ADLs). The MDS documentation R47 received an antianxiety medication during the observation period. R47's Psychotropic Medication Care Plan dated 06/19/2026, documented the resident received psychotropic medication. The care plan documented staff would administer medications as ordered and staff would monitor and document side effects and effectiveness. The staff would consult with the pharmacist and physician to consider dose reduction when clinically appropriate. The care plan lacked directions related to R47's lorazepam (antianxiety medication) as needed for anxiety. R47's Physician's Order, dated 06/01/2026, directed staff to administer lorazepam 0.5 milligrams (mg) every six hours as needed for anxiety PRN. The order lacked a stop date. R47's EHR lacked documentation of specified duration with a physician documented rationale for extended use. On 08/04/2026 at 11:50 AM, R47 was at the dining room table in her Broda chair (specialized wheelchair with the ability to tilt and recline) and staff assisted her to eat lunch. On 8/05/2026 at 08:30 AM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 06/01/2026. Administrative Nurse D verified the facility had not obtained the 14-day stop date or a reason for the continued use with the appropriate rationale and failed to document a stop date to review the medication for indicated need and use. The facilities Use of Psychotropic Drugs, policy dated July 2026, documented residents would receive psychotropic or other approved medications that have an effect on the brain activity when necessary to treat specific conditions for which they are indicated and effective and will not be used for discipline or convenience of staff. The policy documented PRN orders for all classes of psychotropics; antipsychotics the facility would enter a 14 day stop date and to renew the PRN order, the attending physician or prescribing practitioner must evaluate the resident for the appropriateness to write an additional 14 days for that medication. The policy documented on all other psychotropics the facility staff would enter a 14 day stop date, there is documented rationale in the resident's medical record and indication the duration of the PRN order.

Based on observation, record review, and interviews, the facility failed to promote an environment free of hazards for Resident (R) 6, who smoked cigarettes. R6 was assessed for smoking practices by the facility, and the facility documented she required staff assistance, the facility failed to provide her with the necessary safety equipment. Findings included:- R6's diagnoses included nicotine dependence (a chronic brain disorder where the body and mind rely on nicotine,) schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought,) diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin and unsteadiness on feet R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating intact moderately impaired cognition. The MDS documented R6 was independent with activities of daily living (ADL), used a walker to assist with mobility. The MDS documented R6 did use tobacco. R6's Cognitive Loss (CAA) dated 12/16/2025, documented the resident had disorganized thinking, wandering, inattention, and refusal of cares. R6's Smoking Care Plan dated 04/28/2026 directed staff to encourage R6 to wear a smoking apron and ensure the resident was aware of the facility's smoking policy. The care plan directed staff to show R6 where smoking was allowed and how to access the area. The care plan documented the facility would provide residents with requisitions to sign for facility to purchase cigarettes out of their resident account. R6's Smoking Evaluation assessment dated [DATE] documented R6 smoked a flame lit tobacco, could not light her own cigarettes, and required a smoking apron when smoking. The assessment lacked documentation R6 had been given and acknowledged the facility's Community Smoking Rules. On 08/03/2026 at 03:35 PM, observation revealed R6 walked out the patio door and sat on a bench. Continued observation revealed a nurse aide provided R6 with a cigarette and lit it for her. Observation revealed the resident did not have a smoking apron on while smoking her cigarette. On 08/04/26 at 03:40 PM, observation revealed R6 walked out the patio door and sat on a bench. Continued observation revealed a nurse aide provided R6 with a cigarette and lit it for her. Observation revealed the resident did not have a smoking apron on while smoking her cigarette. On 08/05/26 at 04:05 PM, Administrative Nurse D verified R6 was admitted to the facility, and staff evaluated R6 for a Smoking Evaluation assessment and assessed she required a smoking apron when she smoked. Administrative Nurse D verified on the Smoking Evaluation Assessment staff failed to document if R6 had been provided the facility Community Smoking Rules. The Smoking policy, dated September 2024, documented that the facility would establish and maintain safe resident smoking practices. Prior to, or upon admission, residents would be informed about limitations on smoking, including designated smoking areas. Smoking areas would be designated by the community and identified by signage. Smoking restrictions would be strictly enforced in all non-smoking areas, to protect the safety of residents who do not smoke. Residents who wished to smoke would be evaluated for safe smoking per facility protocol, any smoking related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to those issues, per community protocol.

Based on observation, record review, and interview, the facility failed to identify trauma-based triggers related to Resident (R) 21's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) when staff failed to implement individualized interventions to prevent re-traumatization to R21. Findings included:- R21's Electronic Medical Record (EMR) documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), PTSD, and insomnia (inability to sleep).R21's admission Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R21 had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS documented a diagnosis of PTSD.R21's Cognitive Care Area Assessment (CAA) dated 06/01/2026 documented he had disorganized thinking with rejection of cares. R21 was able to communicate his wants and needs. The resident refused to participate in the assessment, so the BIMS was not fully accurate.R21's Care Plan revised on 07/31/2026 directed staff he had behavior problems related to his current diagnoses. The plan directed staff to administer medications as ordered; monitor/document for side effects and effectiveness; anticipate and meet my needs; assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; caregivers to provide opportunity for positive interaction, attention; educate R21 and his guardian on successful coping and interaction strategies; explain all procedures to the resident before starting and allow the resident to adjust to changes; if reasonable, discuss his behavior; as necessary to protect the rights and safety of others; approach/speak to him in a calm manner; minimize potential for my disruptive behaviors by offering tasks which divert attention; monitor behavior episodes and attempt to determine underlying cause; praise any indication of his progress/improvement in behavior; provide a program of activities that is of interest and accommodates the resident's status. R21's plan lacked a care area to address and identify any triggers of his PTSD. The plan lacked intervention to prevent further re-traumatization.R21's EMR documented a Trauma Informed Care Assessment dated 06/05/2026, which documented he had the diagnosis of PTSD. No further information was provided.On 08/04/2026 at 10:15 AM, R21 was in his room and did not want to be disturbed.On 08/05/2026 at 01:05 PM, Social Services X stated the Trauma Informed Care Assessment was attempted on R21, but he refused to divulge any information about any previous trauma he had experienced. Social Services X stated that his care plan should reflect that he had the PTSD diagnosis and direction for staff on things that could cause re-traumatization.The facility's Clinical Protocol: Trauma-Informed Care policy dated August 2026 documented residents, whom are known trauma survivors, will receive culturally competent, trauma informed care in accordance with professional standard of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization; assess residents upon admission and update quarterly and with change of condition. Once established that the resident may have PTSD, assess and/or review the following: triggers that may be stressors or may prompt recall of a previous traumatic event, and the history and physical from referring agency, hospital or setting; to develop the individualized care plan interventions, collaborate with the resident; their family or friends or representatives as appropriate; and any additional health care professionals, e.g. psychologist or mental health professional the resident has seen; as appropriate and available, refer the resident to local support groups, or as able allow the group to meet int he community; attempt to identify the triggers which may re-traumatize the resident and note in the care plan to minimize or eliminate the effect of the trigger on the resident; create trigger specific interventions, examples in chart below; address potential symptoms of trauma.

Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 1's blood glucose (the main sugar in your blood and your body's primary energy source) level was below the physician's ordered parameter and the physician ordered insulin (a hormone that lowers the level of glucose in the blood) was not held. The facility failed to ensure the CP identified and reported when R27's physician ordered parameters for blood pressure and/or pulse were not obtained and recorded prior to the administration of his ordered antihypertensive (a class of medication used to treat high blood pressure) medications. Findings included:- 1. R1's Electronic Medical Record (EMR) recorded diagnoses of type 2 diabetes mellitus (DM -a chronic condition where the body cannot use insulin properly and sugar builds up in the blood), hypertension (HTN- elevated blood pressure), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought).R1's Annual Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with his cares. R1 received insulin injections on seven days during the lookback period. R1's Cognition Care Area Assessment (CAA) dated 02/16/2026 documented the resident had periods of disorganized thinking and inattention. R1 had a diagnosis of schizophrenia and experienced auditory hallucinations (sensing things while awake that appear to be real, but the mind created). R1 was able to make his needs known.R1's Care Plan last revised on 04/13/2026 directed staff to administer diabetes medications as ordered by the doctor. Staff were directed to monitor, document, and report to the physician as needed for signs and symptoms of hypoglycemia (less than normal amount of sugar in the blood). R1's Orders tab of the EMR documented a physician's order dated 03/25/2026 for Novolog aspart (rapid-acting insulin) solution to inject 10 units subcutaneously before meals for DM. Hold when blood sugar (BS) was less than 120 milliliters (ml) per deciliter (dL). Call provider when BS less than 60 ml/dL or over 400 ml/dL.Review of the CP's Monthly Regimen Review (MRR) from January 2026 to July 2026 revealed the CP reported on 04/26/2026 that R1's Novolog was not held when his BS was below 120 ml/dL. The CP reports lacked identifying and reporting when R1's BS was below 120 ml/dL and Novolog should have been held during the months of May and June 2026.Review of R1's April 2026 Medication Administration Record (MAR) revealed his Novolog insulin was not held when his BS was below 120 ml/dL on three of 90 opportunities.Review of R1's May 2026 MAR revealed his Novolog insulin was not held when his BS was below 120 ml/dL on three of 93 opportunities.Review of R1's June 2026 MAR revealed that his Novolog was not held when his BS was below 120 ml/dL on three of 90 opportunities.On 08/05/2026 at 08:45 AM, R1 sat in his room watching tv.On 08/04/2026 at 07:58 AM, Licensed Nurse (LN) G stated the parameters for insulin should be followed and the insulin held when the BS was below the physician's parameters.On 08/05/2026 at 11:55 AM, Administrative Nurse D stated that he would expect the nurse to follow the physician's order on the insulin and when it should be held if below the parameter. 2. R27's EMR documented diagnoses of HTN, major depressive disorder (major mood disorder that causes persistent feelings of sadness) and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought).R27's Annual MDS dated 04/16/2026 documented he had a BIMS score of 11, which indicated a moderately impaired cognition. R27 required moderate assistance from staff for cares. R27 showed inattention and disorganized thinking. R27 received hospice services.R27's Cognition CAA dated 04/29/2026 documented he had noted disorganized thinking and inattention to some conversations. R27 was at increased risk for dementia (a progressive mental disorder characterized by failing memory and confusion).R27's Care Plan last revised on 10/01/2025 directed staff to give antihypertensive medications as ordered. Staff was directed to take blood pressure as ordered.R27's Orders tab of the EMR documented a physician's order dated 06/04/2025 for the beta blocker antihypertensive (medication that lowers the blood pressure and heart rate) propranolol hydrochloride (HCl) 120 milligrams (mg) by mouth in the morning for HTN hold if blood pressure was below 110/60 millimeters of mercury (mm/Hg).R27's Orders tab of the EMR documented a physician's order dated 06/04/2025 for the antihypertensive amlodipine 10 mg daily for HTN hold if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 mm/Hg or the pulse was less than 60 mm/Hg. This order was discontinued on 06/15/2026.R27's Orders tab of the EMR documented a physician's order dated 06/15/2025 for the antihypertensive amlodipine 10 mg daily for HTN hold if systolic blood pressure was less than 100 mm/Hg or the pulse was less than 60 mm/Hg.Review of the CP MRR's from January 2026 to July 2026 revealed that the CP failed to identify and report that R27's blood pressure was not being recorded prior to the administration of propranolol. Review of the MMR's also revealed that the CP failed to report and identify when R27's pulse and blood pressure was not recorded/obtained prior to the administration of Amlodipine.Review of R27's MAR from January 2026 to July 2026 revealed no documented blood pressure or pulse reading with the administration of his amlodipine. R27's documented administration of propranolol from January 2026 to July 2026 on the MAR revealed the blood pressure was not obtained and documented when administered.On 08/04/2026 at 12:50 PM, R27 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room getting ready to receive his noon medications.On 08/04/2026 at 12:50 PM, Certified Medication Aide (CMA) S stated that the physician' parameters should be followed for blood pressure medications. CMA S could not state why R27's blood pressure and pulse was not documented for his amlodipine or propranolol, but she would ask the nurse.On 08/05/2025 at 10:15 AM, Licensed Nurse (LN) I stated that medications parameters should be followed, and she would expect the nurses and CMA's to follow them. On 08/05/2026 at 11:55 AM, Administrative Nurse D stated blood pressure medication orders should be followed as ordered by the physician. Administrative Nurse D stated he would expect the CP to identify when a blood pressure or pulse was not being documented when they should. Administrative Nurse D stated that R27's blood pressure and pulse should be documented on the MAR if there were physician's parameters and he would have to look and see why they had not been.The facility's Pharmacy Services Overview policy dated October 2025 documented the licensed Pharmacist shall collaborate with facility leadership and staff to coordinate pharmacy services within the facility, and to guide the development and implementation of pharmacy services procedures. The facility shall use only individuals authorized under state requirements to provide pharmacy services or administer medications. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director and the Attending Physician (if different) to: develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of all medications and biologicals in the facility; help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers; give the facility's Director of Nursing Services, Medical Director, and staff feedback about performance and practices related to medication administration and medication errors; collaborate with the staff and practitioners to address and resolve medication related needs or problems; help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility.

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1's physician ordered insulin (a hormone that lowers the level of glucose in the blood) was held when the blood glucose (the main sugar in your blood and your body's primary energy source) level was below the physician's ordered parameter. The facility failed to ensure R27's physician ordered parameters for blood pressure and/or pulse were obtained and recorded prior to the administration of his ordered antihypertensive (a class of medication used to treat high blood pressure) medications. The facility failed to ensure R86 had physician ordered parameters for his blood glucose prior to injection of insulin. Findings included: - 1. R1's Electronic Medical Record (EMR) recorded diagnoses of type 2 diabetes mellitus (DM -a chronic condition where the body cannot use insulin properly and sugar builds up in the blood), hypertension (HTN- elevated blood pressure), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R1's Annual Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with his cares. R1 received insulin injections on seven days during the lookback period. R1's Cognition Care Area Assessment (CAA) dated 02/16/2026 documented the resident had periods of disorganized thinking and inattention. R1 had a diagnosis of schizophrenia and experienced auditory hallucinations (sensing things while awake that appear to be real, but the mind created). R1 was able to make his needs known. R1's Care Plan last revised on 04/13/2026 directed staff to administer diabetes medications as ordered by the doctor. Staff were directed to monitor, document, and report to the physician as needed for signs and symptoms of hypoglycemia (less than normal amount of sugar in the blood). R1's Orders tab of the EMR documented a physician's order dated 03/25/2026 for Novolog aspart (rapid-acting insulin) solution to inject 10 units subcutaneously before meals for DM. Hold when blood sugar (BS) was less than 120 milliliters (ml) per deciliter (dL). Call provider when BS less than 60 ml/dL or over 400 ml/dL. Review of R1's April 2026 Medication Administration Record (MAR) revealed his Novolog insulin was not held when his BS was below 120 ml/dL on three of 90 opportunities. Review of R1's May 2026 MAR revealed his Novolog insulin was not held when his BS was below 120 ml/dL on three of 93 opportunities. Review of R1's June 2026 MAR revealed that his Novolog was not held when his BS was below 120 ml/dL on three of 90 opportunities. On 08/05/2026 at 08:45 AM, R1 sat in his room watching tv. On 08/04/2026 at 07:58 AM, Licensed Nurse (LN) G stated the parameters for insulin should be followed and the insulin held when the BS was below the physician's parameters. On 08/05/2026 at 11:55 AM, Administrative Nurse D stated that he would expect the nurse to follow the physician's order on the insulin and when it should be held if below the parameter. 2. R27's EMR documented diagnoses of HTN, major depressive disorder (major mood disorder that causes persistent feelings of sadness), and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R27's Annual MDS dated 04/16/2026 documented he had a BIMS score of 11, which indicated moderately impaired cognition. R27 required moderate assistance from staff for cares. R27 showed inattention and disorganized thinking. R27 received hospice services. R27's Cognition CAA dated 04/29/2026 documented he had noted disorganized thinking and inattention to some conversations. R27 was at increased risk for dementia (a progressive mental disorder characterized by failing memory and confusion). R27's Care Plan last revised on 10/01/2025 directed staff to give antihypertensive medications as ordered. Staff were directed to take blood pressure as ordered. R27's Orders tab of the EMR documented a physician's order dated 06/04/2025 for the beta blocker antihypertensive (medication that lowers the blood pressure and heart rate) propranolol hydrochloride (HCl) 120 milligrams (mg) by mouth in the morning for HTN hold if blood pressure was below 110/60 millimeters of mercury (mm/Hg). R27's Orders tab of the EMR documented a physician's order dated 06/04/2025 for the antihypertensive amlodipine 10 mg daily for HTN hold if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 mm/Hg or the pulse was less than 60 mm/Hg. This order was discontinued on 06/15/2026. R27's Orders tab of the EMR documented a physician's order dated 06/15/2025 for the antihypertensive amlodipine 10 mg daily for HTN hold if systolic blood pressure was less than 100 mm/Hg or the pulse was less than 60 mm/Hg. Review of R27's MAR from January 2026 to July 2026 revealed no documented blood pressure or pulse reading with the administration of his amlodipine. R27's documented administration of propranolol from January 2026 to July 2026 on the MAR revealed the blood pressure was not obtained and documented when administered. On 08/04/2026 at 12:50 PM, R27 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room getting ready to receive his noon medications. On 08/04/2026 at 12:50 PM, Certified Medication Aide (CMA) S stated that the physician' parameters should be followed for blood pressure medications. CMA S could not state why R27's blood pressure and pulse was not documented for his amlodipine or propranolol, but she would ask the nurse. On 08/05/2025 at 10:15 AM, Licensed Nurse (LN) I stated that medications parameters should be followed, and she would expect the nurses and CMA's to follow them. On 08/05/2026 at 11:55 AM, Administrative Nurse D stated blood pressure medication orders should be followed as ordered by the physician. Administrative Nurse D stated that R27's blood pressure and pulse should be documented on the MAR if there were physician's parameters and he would have to look and see why they had not been. The facility's Unnecessary Medications policy dated May 2026 documented residents drug regimen will be free from unnecessary drugs- if any drug is used in excessive dose, including duplicative therapy or for excessive duration, or without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued or any combination of the reasons above. The facility's QAPI Plan: Failure to Follow Blood Sugar Parameters dated April 2026 documented: assess the affected resident immediately for symptoms of hypo (low) or hyperglycemia (elevated blood glucose) and document; treat as parameters indicate by order; notify physician and family as indicated; complete an audit on all residents with orders for blood sugar parameters. Document correction of any identified issues; establish a schedule for ongoing audits of adhering to blood sugar parameters; re-education to all licensed nurses or CMA's for adhering to blood sugar parameters and the documentation associated with the process. - The Electronic Medical Record (EMR) for R86 documented the following diagnoses of atrial fibrillation (rapid heart rate), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R86's Quarterly Minimum Data Set (MDS), dated [DATE], documented R86 had intact cognition. R86 was independent with all activities of daily living (ADL) and received seven days of insulin medication. R86's 06/04/2026 Care Plan documented the following interventions for R86: 4/06/2026-Blood glucose (measures the concentration of glucose in the liquid portion of the blood) levels as ordered, diabetes medication as ordered by doctor, and monitor for side effects and effectiveness. Obtain a dietary consult for nutritional regimen and ongoing monitoring and educate R86 regarding medications and the importance of compliance. The care plan directed staff to obtain fasting serum blood sugars as ordered by the physician. The Physician's Order, dated 01/30/2026, directed staff to administer insulin glargine (a long-acting insulin), 30 units, subcutaneously (beneath the skin), at bedtime for diabetes mellitus. The Physician's Order, dated 11/17/2025, directed staff to obtain blood sugars daily. The order lacked blood sugar parameters. On 08/04/2026 at 09:00 AM, R86 was in the hospital. On 08/05/2026 at 09:15 AM, Licensed Nurse (LN) I stated, per her nursing judgment, the insulin would be held if his blood sugars were under 60 milligrams per deciliter (mg/dL). At 09:15 AM, LN I stated she updated the EMR with blood sugar parameters. On 08/05/2026 at 09:30 AM, Administrative Nurse D stated there should be parameters for all residents who received insulin. Upon Request, a policy for obtaining blood sugar levels was not provided by the facility.

Based on observation, record review, and interview, the facility failed to ensure biologicals were properly monitored for safe storage temperatures, dated upon opening, maintained within safe expiration dates, and secured to prevent unauthorized access. This deficient practice affected 1 of 1 medication room refrigerators and 4 resident-specific insulin (a hormone that lowers the level of glucose in the blood) pens, Resident (R) 13, R75, and R72. Findings included:- On [DATE] at 07:35 AM, observation of the medication cart for Hall A&B located adjacent to the nurses station revealed Resident (R) 13's Lantus (long-acting insulin) flex pen was not labeled with an opened date or an expired date, and R13's Novolog (fast -acting insulin) insulin flex pen that had a date written on the pen -but it had smeared and was not legible. On [DATE] at 07:50 AM, observation of the medication cart for Hall C located next to the nurses' station revealed R86's Lantus vial was labeled with the date opened [DATE] (44 days), and R75's Basaglar (long acting) insulin flex pen was labeled with a date opened of [DATE] (44 days). On [DATE] at 07:20 AM, Licensed Nurse G verified the nurses should label and date the insulin flex pens and insulin vials with the date opened. On [DATE] at 8:20 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened and discard the outdated insulin. Medlineplus.gov directs open, unrefrigerated Basaglar, Lantus, and Novolog can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medications policy, dated [DATE], documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulations. The facility's Insulin Administration policy, dated [DATE] documented when the nurse administered insulin to resident's she would check expiration date, if drawn from an open multi-dose vial, when opening a new vial, record expiration date and time on the vial, (follow manufacturer recommendations for expiration after opening). - On [DATE] at 08:39 AM, observation in the medication room revealed the temperature log for the medication refrigerator lacked daily temperatures for 12 days in July and four days in August. Administrative Nurse E stated the night shift nurse was responsible for the temperature log in the medication room and verified there were missing signatures for the days in July and [DATE]. On [DATE] at 09:30 AM, Administrative Nurse D stated that the night nurse who was responsible for making sure the temperatures were taken for the medication room refrigerator had been on vacation during the days that lacked documentation, and he usually checked the temperatures also, but he had been gone during that time also. The facility's Medication Distribution policy, dated 01/204, documented that insulin and other medications requiring refrigeration should be stored separately in the medication room. Each medication should be placed in the refrigerator and stored in a zip-lock bag or plastic basket labeled with the resident's name and unit number. The refrigerator should not be used for any non-medical items. If medications stored in the refrigerator must be temporarily removed, ensure that they are maintained at the appropriate temperature. The refrigerator should have a hanging thermometer in it, and the temperature must be maintained to an appropriate level for storage of meds: 37-42 degrees F. Employees are to monitor this daily and log the temperature on the medication refrigeration temperature log form.

Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)47 and R27. Findings included:- 1. R47's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), arteriosclerotic heart disease (a condition where fatty plaque builds up inside the arteries that supply blood to the heart), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R47's Quarterly Minimum Data Set (MDS) dated [DATE], recorded R47 had moderately impaired cognition. The MDS recorded that R47 required staff assistance with all activities of daily living (ADLs). The MDS lacked documentation R47 received hospice services. R47's Activities of Daily Living Care Plan dated 06/19/2026 documented R47 required extensive assistance with most ADL. R47's End of Life Care Plan dated 06/20/2026, documented R47 had chosen end of life care with another hospice. The care plan directed staff to administer medications for comfort prior to activity/care. Assist with supporting ADL function of bathing, eating, grooming and hygiene, toileting-continence- related tasks including control and hygiene, and assistance for fatigue, loss of strength, and sleep. The care plan lacked the current hospice provider, instruction on the services provided by hospice including hospice staff visits, supplies and medical equipment provided by the current hospice, and medications covered by hospice. Review of R47's medical record revealed R47 was admitted to hospice care on 08 /20/2024. On 02/18/2026, the resident chose the current hospice provider. The medical records lacked evidence of the current hospice provider and the coordination of care between hospice and the facility. On 08/04/2026 at 11:50 AM, R47 was at the dining room table in her Broda chair (specialized wheelchair with the ability to tilt and recline), and staff assisted her to eat lunch. On 08/05/2026 at 08:30 AM, Administrative Nurse D stated he expected the facility to have a hospice care plan for R47 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan that coordinated with the facility care plan and verified the facility care plan documented the previous hospice the resident was on but acknowledged she had recently been admitted to a new hospice and that information was not in the care plan including what services the present hospice would provide for the resident. - 2. R27's EMR documented diagnoses of HTN, major depressive disorder (major mood disorder that causes persistent feelings of sadness), and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R27's Annual Minimum Data Set (MDS) dated 04/16/2026 documented he had a BIMS score of 11, which indicated moderately impaired cognition. R27 required moderate assistance from staff for cares. R27 showed inattention and disorganized thinking. R27 received hospice services. R27's Cognition Care Area Assessment (CAA) dated 04/29/2026 documented he had noted disorganized thinking and inattention to some conversations. R27 was at increased risk for dementia (a progressive mental disorder characterized by failing memory and confusion). R27's Care Plan revised on 08/20/2024 directed staff that he was on hospice services. The plan directed staff to: provide activity as tolerated; administer medications for comfort prior to activity/care (Pain medications/respiratory treatments) as ordered; Assist with supporting ADL function of bathing to the extent needed. Assist with supporting ADL function of eating to the extent needed. Assist with supporting ADL function of grooming and hygiene to the extent needed. Assist with supporting ADL function of toileting- continence-related tasks including control and hygiene to the extent needed. Assistance for Fatigue, Loss of Strength, Sleep; Keep resident comfortable to the extent possible. The plan lacked information about how often hospice staff would make visits, what supplies and medications hospice would provide, and lacked information on what durable medical equipment (DME) hospice would provide. R27's hospice provider binder lacked a plan of care (POC) with all the required information. The binder lacked the most recent recertification order and information. On 08/04/2026 at 12:50 PM, R27 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room getting ready to receive his noon medications. On 08/05/2026 at 10:02 AM, Certified Nurse Aide (CNA) M stated that usually the nurse would let staff know when a resident was on hospice and would let them know what hospice provided the resident. CNA M stated each resident had a hospice book at the nurses station. On 08/05/2026, Licensed Nurse (LN) I stated that the hospice book should have all the information on what hospice provided in the POC. The residents care plan should reflect the same information as what the POC has in it. The facility's Hospice Program policy dated December 2025 documented to obtain a physician's order for Hospice services to include diagnosis. Including physician's orders the for prognosis and the basis for prognosis that match the hospice information on the certification of terminal illness; clarify the residents advanced directives and preferences for end-of-life planning; along with the hospice provider, discuss, plan and obtain orders for preferences in pain management, symptom control, treatment of acute illness, and choices regarding hospitalization; obtain the physician certification or re-certification for hospice services; post the 24-hour access number for the resident's hospice provider; the hospice provider(s) should be set up in Point Click Care (PCC) and attached to the resident's profile within the chart; identify a member of the IDT who is responsible for working with the hospice representative. This person must have a clinical background and has the ability to assess the resident within state scope of practice or have access to someone who can complete that function. These responsibilities include collaboration and coordination of hospice care; communication with hospice representatives and other health care providers participating in the hospice care; ensuring the hospice medical director and the attending physician or other practitioners collaborate and communicate to coordinate the hospice care; ensuring the appropriate documents are readily available. The hospice provider may have access and can document in PCC the care provided. A nursing progress note stating hospice saw the resident and notes to follow etc. should be documented in the progress notes. If the hospice does not document in PCC the community may include selecting one personal to scan and upload hospice documents to the resident's electronic medical record no more than five days after documents are received as outlined below), to include; the most recent hospice plan of care; hospice election form; physician certification for terminal illness; names and contact information of hospice personnel involved for each resident; instructions for the 24 hour on call system; hospice medication and supplies specific to each resident; hospice physician and attending physician orders specific to each resident; visit notes from all hospice disciplines, nurse, chaplain, social services, and volunteer; ensuring that the community staff provides an orientation to the policies and procedures of the community, including resident rights, appropriate forms, and record keeping requirements.

The facility identified a census of 94 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent and then identify an elopement for Resident (R) 1, who had a BIMS of 15, schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and a guardian. On 02/05/26 at 02:45 AM, R1 left the facility without staff knowledge or supervision by climbing a fence surrounding a smoking patio at the facility and using a dining room chair. Staff were unaware of R1's absence for nine hours due to a failure to complete resident safety rounds. R1 walked to a truck stop and stayed there for hours before walking back to the facility. R1 walked in temperatures ranging from 29.9 to 45.3 degrees F during the timeframe of 02:45 AM to 11:45 AM when he returned to the facility. This failure placed R1 in immediate jeopardy. Findings included:- R1's Electronic Medical Record (EMR) documented a diagnosis of schizoaffective disorder. The Annual Minimum Data Set (MDS) dated 12/30/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person, although evidence shows it was untrue). R1 had rejection of cares and wandering behaviors on one to three days in the assessment period. The Behavioral Symptoms Care Area Assessment (CAA) dated 01/02/26, documented R1 triggered for behaviors of wandering and rejection of cares. R1's 01/26/23, revised 02/05/26, Care Plan documented R1 was at moderate to high risk for an elopement. The Care Plan documented the following interventions:02/05/26- Staff increased supervision during increased exit seeking behaviors.02/05/26- Staff provided a room away from an exit.02/05/26- Staff provided lodging in a secure unit.02/05/26- Staff requested a medication review from the pharmacist, medical doctor, or registered nurse.02/05/26- Staff requested psychiatric services as needed.02/05/26- Staff utilized a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering), checked placement of the WanderGuard each shift and the function each day. Staff utilized the WanderGuard per manufacturer's recommendations. R1 had a WanderGuard that limited his ability to enter the backyard without staff present. The facility's investigation documented on 02/05/26 at 11:45 AM, R1 requested re-entry at the front door. Staff brought him back inside and assessed him for injury, for which he had none. Staff placed a WanderGuard that locked the smoking area patio door so he would have to ask staff to go outside. The facility inspected the smoking patio and found a dining room chair which staff removed immediately. R1 wore a hooded sweatshirt, long denim pants, and closed-toed shoes. The facility notified R1's guardians of the incident and of the WanderGuard which the guardians agreed to. R1 reportedly climbed the fence earlier that morning and ran away. The facility reviewed their cameras and noted R1 used a chair to climb the fence on the smoking patio at 02:45 AM on 02/05/26. R1 reported he went to a nearby gas station and stayed there a while before making the decision to return to the facility. The facility immediately re-educated staff to visibly check each resident frequently and to remove and moveable furniture on the smoking patio when they see it. On 02/05/26, R1 stated he had intentions to leave the facility and when asked why, he replied he did not know. R1 reported he sat at the gas station for a few hours before he decided to return to the facility. According to the Kansas State University Historical Weather website, the temperatures on 02/05/26 between 02:45 AM to 11:45 AM ranged from 29.9 degrees Fahrenheit (F) to 45.3 degrees F. Review of Google Maps revealed the distance from the facility to the truck stop was 1.8 miles. In a written statement, not dated, Certified Nurse Aide (CNA) M stated the last time she saw R1 was at 09:00 PM for a smoke break and he acted like his normal self. In a text statement, not dated, CNA N stated she could not recall the exact time she saw R1 walking around but she believed it was before midnight. In a text statement, not dated, Certified Medication Aide (CMA) R stated the night went smooth and she did not recall seeing R1 all night. In a text statement, not dated, Licensed Nurse (LN) G stated she believed she last saw R1 ambulating in the hallway and dining room around 02:00 AM. She stated R1 gave no indication of any concerns or unrest during the night. On 03/05/26 at 12:22 PM, Administrative Staff A escorted the surveyor through the dining room to the back door that opened up into a patio area surrounded by a tall fence. The patio area had no readily movable furniture available. On 03/05/26 at 12:26 PM, R1 laid in bed with his blankets pulled up to his chin. He did not want to engage in conversation other than to state he remembered the incident and that he was okay being in the facility. The WanderGuard was not visible at the time of the observation due to the blankets being pulled up to R1's chin. On 03/05/26 at 02:42 PM, the area where R1 climbed the fence was observed to be behind the facility and an employee parking area. The area had several large potholes. Observation of the probable path that R1 took to get to the truck stop revealed posted street signs of 30 miles per hour (mph) to 45 mph with areas of residential and commercial buildings. The street leading to the truck stop had commercial buildings on either side of the street with semi-trucks entering and exiting the street. The street leading to the truck stop did not have a sidewalk on either side of the street. The truck stop was located within a block of the on/off ramps of an interstate. On 03/05/26 at 12:22 PM, Administrative Staff A stated he observed R1 on the camera, using a dining room chair against the fence to climb over it. He stated the door to the patio remained unlocked but R1 had a WanderGuard that alarmed at the door and told him he needed staff if he wanted outside. On 03/05/26 at 12:27 PM, Administrative Staff A stated on 02/05/26, staff did not round on R1. He stated LN G was the last to see R1 in the dining room and she did not do rounds the rest of the shift. Administrative Staff A stated he took statements from day shift that day and not one of them said they did rounds when they took over their shift. On 03/05/26 at 12:31 PM, CMA S stated she worked on 02/05/26 and she was on her lunch break at the time R1 returned. She stated she did not complete rounds that day and R1 did not get medications from her during the day. CMA S stated she now completed rounds when she came in and before she left. She stated she kept residents safe from elopement by having eyes on them frequently and interacting with them. She stated residents at risk for elopement wore a WanderGuard that the nurses checked the function of and the CNAs checked the placement. She stated R1's WanderGuard locked the door to the patio yard. On 03/05/26 at 12:35 PM, LN H stated she worked on 02/05/26 and she completed rounds in the morning but R1's curtain was pulled, and she did not go into his room to see where he was. She stated R1 came back to the facility, and she asked him where he went and R1 stated he jumped the fence. She stated she completed a skin assessment right away then took him to Administrative Staff A. LN H stated he was fully clothed like he was going outside. She stated she kept residents safe from elopement by completing rounds every two hours and if somebody did not do their rounds, she sent them home. LN H stated she told her CNAs to look at the resident face-to-face and if they could not find a resident, they looked for them. On 03/05/26 at 12:39 PM, Administrative Nurse D stated on 02/05/26, R1 hit the button to come back into the facility and LN H let him in. She stated LN H asked him where he had been and how he got there and R1 stated he went to the gas station and meant to come back to the facility, but he fell asleep on the couch. Administrative Nurse D stated she noted he wore tennis shoes, a jacket, jeans, and a t-shirt. She stated R1 now had a WanderGuard that prevented him from going into the backyard without staff assistance. She stated after the incident, the facility reassessed all of the residents for elopement to make sure their care plans were current. Administrative Nurse D stated after the incident, the facility made sure staff completed their rounds, the facility educated staff on rounds and elopement, and the facility completed an elopement drill. The facility's Accidents- Elopement policy, dated June 2025, directed staff promptly reported any resident who tried to leave the premises or was suspected of being missing to the charge nurse or Administrative Nurse D. On 03/05/26 at 02:35 PM, Administrative Staff A was presented with the Immediate Jeopardy (IJ) Template and was notified of the facility failure to provide adequate supervision to prevent the elopement of R1, which constituted immediate jeopardy at F689. The immediate jeopardy at F689 also constituted Substandard Quality of Care at 42 CFR 483.25. The facility identified, implemented, and completed the following corrective measures:1. The facility updated R1's care plan on 02/05/26.2. The facility placed a WanderGuard on R1 on 02/05/26.3. The facility conducted education on elopement and rounds with staff on 02/05/26.4. The facility gave written warnings to multiple staff for failure to complete rounds on 02/05/26.5. The facility completed magnetic lock checks on the doors on 02/05/26 and 02/06/26.6. The facility completed an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 02/06/26.7. The facility completed an elopement drill on 02/07/26. Due to the facility completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a J (isolated, immediate jeopardy).

The facility identified a census of 93 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from verbal abuse. On 01/19/26 at approximately 03:20 PM, Dietary Staff (DS) BB verbally abused R2, and Certified Medication Aide (CMA) R had to step between DS BB and R2 in order to assist R2 out of the situation. Per the interview with Administrative Staff A and CMA R, DS BB called R2 an [expletive] during the incident. The facility's failure to ensure staff did not verbally abuse residents placed R2 in immediate jeopardy.Findings Included:- R2's Electronic Medical Record (EMR) documented diagnoses of paranoid schizophrenia (chronic mental health condition characterized by intense, irrational suspicions, persecutory delusions, and auditory hallucinations), anxiety disorder (mental health condition characterized by persistent, excessive fear or worry that is out of proportion to actual danger and interferes with daily life), shortness of breath, and malignant neoplasm of the breast (breast cancer). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R2 was independent for Activities of Daily Living (ADL).The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/11/25 documented R2 had periods of inattention and disorganized thinking. R2 had diagnoses of paranoid schizophrenia and anxiety. The CAA documented R2 had been psychotic (loss of contact with reality, characterized by symptoms like hallucinations and delusions) and voiced delusions. R2 could stay focused during the beginning of the conversation, but as the conversation went on, R2 became more delusional. The CAA documented R2 continued to be at risk for fluctuations in cognition.R2's 01/07/17 Care Plan documented R2 had a diagnosis of paranoid schizophrenia. The Care Plan documented the following interventions:06/05/21 - Staff were to allow R2 to voice needs and concerns, redirect or offer distraction as needed.01/07/17 - Staff were to avoid colliding with hallucinations, delusions, or attempts to argue, the resident of delusions.09/28/17 - Staff would know if R2 was escalating, staff were to attempt to redirect R2 to a quiet area where R2 could calm down. Staff would also consider giving R2 as needed medication to help R2 feel better. Staff were directed to recognize that it may be difficult to redirect R2 when she was delusional. Staff needed to be patient with the resident and offer quiet reassurance.01/12/17 - Staff were to encourage R2 to express her feelings or concerns and will address them as appropriate. This may include encouraging R2 away from the triggering situation to prevent further escalation and assist with de-escalation01/12/17 - Staff were to interact with R2 in naturally occurring situations to build rapport and monitor for possible precursors to socially inappropriate behaviors. An IDT Note: General dated 01/19/26 documented R2 was at 03:00 PM snack pass. R2 was yelling and screaming with another staff member. The note documented that both the staff and R2 were separated.The facility's investigation CP2721160 documented it was reported to Administrative Staff A that DS BB was shouting in the dining room at R2. DS BB was sent home pending the investigation and cameras were reviewed. DS BB could be seen yelling and screaming at R2 in front of other residents. DS BB could be heard shouting profanities and using vulgar and offensive references at R2. Several nursing staff came to intervene and calm the situation. DS BB was then immediately sent home. The investigation documented an interview was conducted with R2 and R2 stated that she was asking DS BB for another snack when DS BB went off. R2 admitted that she shouted back at DS BB. R2 reported staff intervened and helped calm her down and supported her, and that she felt comfortable and safe at the facility. The investigation documented DS BB's behavior, as seen on camera, was not accepted by the facility. The facility terminated DS BB's employment on 01/20/26 while she was still away on suspension. The investigation documented the following corrective actions were taken: the facility immediately separated residents and staff, suspended DS BB, reviewed cameras and terminated the staff member. The investigation documented the plan for monitoring ongoing effectiveness was the staff member was terminated.The investigation lacked any further corrective actions or plans for monitoring ongoing effectiveness.The facility investigation lacked any staff witness statements.R2's EMR lacked evidence of any follow-up psychosocial assessments or staff interviews with R2 related to the incident.On 01/28/26 at 01:04 PM, R2 lay in bed resting, in her room. R2 stated she remembered the incident but could not remember what was said to her specifically. R2 stated she was only asking for more food when she was yelled at. R2 stated it was nothing new or out of the ordinary to be yelled at by staff and stated she was yelled at all of the time. R2 stated she did not feel safe when she was yelled at. During interview, R2 began to fall asleep and did not answer any further questions.On 01/28/26 at 02:04 PM, CMA R stated staff and residents were in the dining room doing snacks. CMA R stated she heard screaming coming from the dining room. She stated there were residents around the snack area, but she could hear who was yelling. CMA R stated she knew the voices and knew it was DS BB and R2. CMA R stated she heard DS BB call R2 an [expletive]. She stated R2 yelled back I am not an [expletive]. You cannot talk to me that way. This is my home you cannot treat us like this in our home. She stated DS BB tried to get in R2's face. CMA R stated she got between them and got R2 to focus on her and tried to help remove R2 from the situation. CMA R stated, I was trying to get R2 out of the hostile environment. She stated she was not sure if DS BB threatened R2, but she did hear her call R2 an [expletive]. CMA R stated R2 was not getting into anyone's face and was not going after staff. CMA R stated she was able to get R2 to back away and eventually got her outside. CMA R stated she was unsure if there had been any training provided after the incident as she was off work after it happened. She stated they normally did training with staff when there was an altercation, but she was not sure about this time. CMA R stated staff did ANE training yearly and she had taken it prior. CMA R stated R2 did not seem any different after the incident. She stated sometimes R2 had good days and bad days. CMA R stated she had not observed R2 being afraid of anyone and she appeared to be her normal self. On 01/29/26 at 12:20 PM, Social Services X stated she was not aware of the incident between DS BB and R2. She stated she knew there was an incident but did not know the details of it. Social Services X stated she had not completed any psychosocial follow up with R2 related to the incident. She stated she or Social Services Y would often do psychosocial follow ups if they were warranted. Social Services X stated psychosocial assessments are documented in progress notes or sometimes under assessment in the EMR. On 01/29/26 at 02:17 PM, Social Services Y stated there was a verbal altercation between DS BB and R2 and it was very rude and inappropriate. She stated DS BB used curse words several times and it was very inappropriate and uncalled for. Social Services Y stated she spoke to R2 the next day and R2 reported to Social Services Y she felt safe in the facility and went to the dining room. Social Services Y stated R2 said she did not want to deal with DS BB anymore. Social Services Y stated DS BB had already been taken care of by leadership staff as DS BB was fired before R2 encountered her again. Social Services Y stated she saw R2 every day and would ask if R2 needed anything or had anything she needed to talk about. Social Services Y stated R2 would always go off on a tangent but had not talked about the incident with Social Services Y. Social Services Y stated she did not want to bring up issues as she did not want to traumatize R2 again. Social Services Y stated if residents had a problem they would tell her. Social Services Y stated she just did a general check-in with R2. She stated when she heard about an issue she would check in to make sure residents were not upset. Social Services Y stated the check ins were only done verbally, and were generalized check ins. She stated nothing was officially documented related to her checking in with the residents after an incident. Social Services Y stated R2 had cancer and a wide range of behaviors. Social Services Y stated R2 would sometimes be alert and with it, and at other times R2 was delusional and yelled at staff. She stated R2 was at baseline and denied any changes in behavior related to the incident.On 01/28/26 at 11:17 AM, Administrative Staff A stated the situation went from 0 to 100 quickly. Administrative Staff A stated he sent DS BB home quickly and then reviewed the camera footage. He stated he did not hear DS BB make threats but did hear DS BB use vulgar language. Administrative Staff A stated DS BB called R2 an [expletive] and he could hear it on the camera's audio. Administrative Staff A stated staff intervened and got between the two and named CMA R as a direct witness to the incident. He stated after he reviewed the camera footage DS BB was contacted and her employment was terminated. Administrative Staff A stated he did not take down any witness statements in his investigation as he saw and heard everything on camera. Administrative Staff A stated he typically leaned more on the camera footage as he could see and hear everything. He stated that sometimes witness statements could be biased, exaggerated, or downplayed. Administrative Staff A stated there was no staff education completed after the incident as DS BB was terminated, and the other staff had previously had ANE training. Administrative Staff A stated other staff knew what had happened was not okay and it was not acceptable. He stated staff intervened appropriately in relation to the incident. Administrative Staff A stated R2 only asked for more food when DS BB yelled at her. He stated R2 did not deserve to be treated like that and did not report any concerns or grievances to him after the incident. The facility's Abuse Prevention Program F 600 policy, dated 08/2025, documented residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment resulting with physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental or psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. On 01/29/26 at 05:01 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to ensure R2 remained free from verbal abuse placed R2 in IJ.The facility provided an acceptable plan for removal of the immediate jeopardy on 01/29/26 at 06:39 PM. Which included the following:The facility would conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported. This would be completed by 01/30/26 at 05:00 PM.The facility would educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility. The facility would also complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report. This would be completed on 01/29/26 and/or prior to their next scheduled shift.The survey team validated the immediate jeopardy was removed on 01/30/26 at 10:20 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a D following the removal of the immediate jeopardy.

The facility reported a census of 96 residents, with 31 residents assessed at risk for elopement (when a resident leaves the premises or safe area without staff knowledge), and five residents sampled. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision and appropriate interventions to prevent the elopement of cognitively impaired R1, who had poor safety awareness. On 01/23/25 at approximately 04:58 PM, R1 exited the facility, unimpeded and without staff knowledge, and R1 remained out of the facility without staff knowledge for approximately 45 minutes, with outdoor temperatures between 16 and 18 degrees Fahrenheit (F). Local law enforcement located R1 approximately 43 minutes later at 05:45 PM, and returned R1 to the facility. This deficient practice placed R1 in immediate jeopardy at risk for life-threatening physical injury or harm. Findings included: - The Electronic Medical Record (EMR) documented R1 was admitted to the facility on [DATE] and had diagnoses of: schizoaffective disorder bipolar type (a mental health condition marked by a mix of symptoms, such as hallucinations, delusions, and mood disorder symptoms, such as depression, and mania), diabetes mellitus without complications (a disorder characterized by the body's inability to metabolize sugar), and dysphagia, oropharyngeal phase (a disorder or impairment on the inability to swallow). The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The MDS documented R1 had inattention and disorganized thinking, which was continuously present and did not fluctuate. The MDS documented R1 experienced delusions, hallucinations, rejection of care, and episodic wandering for one to three days during the seven-day assessment period. R1 ambulated with the use of a rolling walker. The 12/11/24 Cognitive Loss/Dementia Care Area Assessment (CAA) identified R1 at risk for decreased activity involvement due to refusal to engage in assessments, frequent visual and auditory hallucinations, fluctuating mood cycles, and medication refusals. This same assessment recorded a Care Plan would be developed to address the resident's at-risk status. R1's recent Quarterly Elopement Risk assessment dated [DATE] recorded R1 was not at risk for elopement with a score of zero. R1's Care Plan initiated on 05/04/21, and last reviewed on 12/26/24, recorded R1 as at risk for elopement related to making statements she was leaving or moving. The care plan directed staff to assess for risk of elopement per facility policy, redirect residents from doors, and the placement of a WanderGuard (a bracelet-worn signaling device when a resident nears an exit) located on R1's left wrist. The staff were to check the WanderGuard every shift to ensure function. The facility would replace the resident's WanderGuard every 90 days or as needed. R1's Care Plan recorded she had behaviors such as delusional thinking, paranoia, hallucinations, repetitive movements, pacing, wandering, and others related to R1's diagnoses. The Care Plan directed staff to allow R1 to voice her needs and concerns, provide distraction, as needed, and monitor R1 for possible changes in mental status, agitation, confusion, and restlessness. The Care Plan lacked documentation of any new interventions implemented after R1's elopement on 01/23/25. A Nurses Progress Note dated 01/23/25 at 06:10 PM recorded R1eloped from the facility to the street, where city police found the resident. The police contacted the facility, brought R1 back to the facility, and staff received R1 at the facility entrance. R1 was assessed with no new skin issues noted. The Nurse Notes lacked any health assessment of the resident such as R1's vital signs, and physical, emotional, and/or cognitive/mental state upon return to the facility after the elopement. The Facility Investigation documented review of video surveillance cameras recorded: On 01/23/25 at 04:58 PM R1 looked at the exit sign at the end of A Hall, pushed the doors open, and exited the door. The investigation also noted Police contacted R1 at 05:27 PM approximately 500 feet from the building, and R1 offered an [NAME] (different name). R1 had a cell phone and where Police saw the facility's address and surmised R1 was a resident of the facility. Law Enforcement returned R1 to the facility at 05:43 PM. The facility report documented R1 wore a black jacket, long pants, gloves, and closed-toed shoes. The facility's investigation lacked witness statements regarding R1s elopement from the facility. According to Weather Underground, (www.wunderground.com), on 01/23/25 at 04:53 PM, the temperature was 18 degrees F, with a west-northwest wind at eight miles per hour (mph). At 05:53 PM the temperature dropped to 16 degrees F and wind speed decreased to 3 mph. The facility investigation documented a detailed explanation of loose wiring caused a power interruption and the door's malfunction. This power source (located externally on the wall above the door), also prevented the alarm from sounding to alert staff of R1's exit. The exit door was not equipped with a WanderGuard (wall unit) alert system. On 01/29/25 at 11:00 AM, R1 slept in a chair, in the facility's common area. At 12:49 PM R1 rested in her room. On 01/29/25 at 12:49 PM, R1 reported she was doing ok, but people kept making her fall. R1 said others try to make her fall flat on her face. R1 stated she goes out but does not smoke anymore. R1 would not respond to any questions about being outside the facility and/or leaving the facility grounds. R1 ended the conversation by stating, I'm done talking to you, I'm not going to repeat myself. On 01/29/25 at 03:00 PM, Administrative Nurse D acknowledged R1 had a noninjury fall on 01/21/25, was assessed, and doing ok. Administrative Nurse D acknowledged that R1 had poor safety awareness. On 01/29/25 at 03:00 PM, Administrative Staff A stated the facility WanderGuards (wall unit) were located on the two front doors and a back door, but not the door R1 exited the building from. Administrative Staff A stated the doors were checked daily for function, but maintenance failed to routinely check the wiring and/or power source at the door. Administrative Staff A did not know why the resident was not seen exiting due to the door's location being within sight of the nurse station. A review of the facility's F689 Accidents -Elopement policy revised August 2024 recorded a definition of elopement as follows: A situation in which a resident leaves the premises or a safe area without the facility's knowledge or supervision if necessary and this situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. The policy recorded all residents would be assessed for elopement risk status and at-risk residents, would be care planned with interventions to address wandering and/or exit-seeking behaviors. This policy noted that at-risk residents would be monitored by staff supervision. This policy further recorded a resident with decision-making capacity, leaving the facility intentionally is considered an elopement if the facility is unaware of the resident's departure and/or whereabouts. The policy further recorded that new wandering behavior or attempted elopement would be documented in the nurses' notes and the resident's care plan would be updated to include increased monitoring. The facility failed to provide adequate supervision and appropriate interventions to prevent R1, who was diagnosed with psychiatric illness and identified, as at risk for elopement, from exiting the facility without staff awareness. For approximately 45 minutes facility staff did not know R1 was missing in freezing weather until law enforcement returned R1 to the facility. This deficient practice placed R1 in immediate jeopardy for potentially life-threatening injury. On 01/29/25 at 03:21 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy Template and informed of the facility's failure to provide adequate supervision and appropriate interventions to prevent R1 from elopement, placed R1 in immediate jeopardy. The facility completed the following corrective actions to remove the immediacy for R1: Staff conducted a headcount ensuring the safety of all residents in the facility. Camera footage was reviewed, identified the malfunction, and effected immediate repairs on the faulty exit door. Audited all doors and windows to ensure no similar situations existed. Reported the issue to the stated agency, physician et al. Conducted all staff in-service How to check Doors for Lock function on 01/23/25, 01/24/25, and 01/25/25. Conducted an Ad Hoc QAPI meeting with the Executive Director, (ED) Director of Nursing (DON), and Medical Director (MD). The Medical Director was requested for feedback and had nothing further to add or suggest. The Surveyor verified the facility completed the above corrective actions prior to the onsite survey on 01/29/25, therefore the deficient practice was deemed past-noncompliance at a J scope and severity.

The facility had a census of 94 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 94 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 08/20/24 at 10:00 AM, a review of the noon meal consisted of meatloaf, Capri vegetables, a dinner roll, and strawberry cake. On 08/20/24 at 11:30 AM, observation revealed Dietary Manager (DM)BB in the kitchen overseeing the preparation of the noon meal. On 08/19/24 at 11:32 AM, DM BB verified she was not a certified dietary manager. Dietary Staff BB stated she had finished the classes but had not scheduled a date to take the test. On 08/20/24 at 02:33 PM, Administrative Staff A verified DM BB had no dietary manager certification. The facility's Food Service Staffing Policy, revised 10/2022, documented that if the facility dietitian was not full-time, then the facility would employ another qualified nutritional professional to serve as the Dietary Manager. The dietary manager must meet one of the following qualifications: A certified dietary manager, A certified food service manager, Had a similar certification in food service management and safety from a national certifying body, Had an associate or higher degree in food services management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning, had two or more years of experience in the position of dietary manager in a nursing facility setting and had completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving and met the states established standards if applicable. The facility failed to employ a full-time certified dietary manager for 94 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 94 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 08/20/24 at 11:29 AM, observation in the kitchen revealed the following A white upright freezer had approximately three-quarters-inch thick ice buildup on the inside including the shelves, sides, top, and bottom. The middle section of the three-door silver refrigerator had four uncovered, undated, unlabeled bowls of cantaloupe verified by Dietary Staff (DS) CC, who stated they should be covered, dated, and labeled. DS CC discarded the cantaloupe. The serving window had numerous different-sized areas with missing Formica. The wall located underneath the place where the dirty dishes came into the dishwasher area had numerous different-sized blackish streaks running down to the floor, which extended approximately two to three feet wide from the disposable to the dishwasher. The caulking, approximately six feet long, located between the dish table and the wall had a black substance. The ceiling located between the oven hood and the wall had a missing piece of sheet rock approximately three feet long by one foot wide, covered with a taped piece of plastic. The floor located in front of the refrigerators had an approximately two-foot by one-foot piece of missing tile. The August 2024 refrigerator/freezer logs lacked temperature documentation on the following dates: The bread refrigerator - 08/08 and 08/16 in the morning (AM), 08/12,08/13, and 08/18 in the afternoon (PM). The walk-in freezer -08/13 and 08/18 in the PM. The walk-in refrigerator 08/13 and 08/18 in the PM. The white upright freezer 08/13, 08/16, and 08/18 in the AM. On 08/20/24 at 12:00 PM, Dietary Manager (DM) BB verified the issues in the kitchen and stated staff should cover, label, and date food items placed in the freezer. DM BB stated she was unaware of why the missing area of sheet rock was covered with plastic; she assumed the kitchen pipes above it had a leak at some point in time. DM BB stated staff should clean the wall underneath the dishwasher and she would get maintenance to replace the caulking by the dishwasher table. DM BB stated staff should check the temperatures of the refrigerators and freezers twice a day and document them on the log sheet. On 08/20/24 at 02:33 PM, Administrative Staff A verified the missing piece of ceiling sheetrock and stated at one time there was a leak in the pipe above the area, but it had been fixed and the plastic should have been removed and replaced with sheetrock. The facility's Supervision, Maintenance Services Policy, revised 09/2023, documented the maintenance director was responsible for scheduling preventive maintenance service. The facility's Sanitation Policy, revised 10/2022, documented the food service area would be maintained in a clean and sanitary manner. The facility's Food Safety Requirements Policy, revised 10/23, documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated. The functioning of the refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food service manager or designee and documented according to state-specific requirements. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 94 residents who received their meals from the facility's kitchen. This placed the 94 residents at risk for foodborne illness.

The facility had a census of 94 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)35, R19, R38, and R72 or their representative with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R35's Electronic Health Record (EHR) revealed a diagnosis of cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of fatty deposits inside the artery walls), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and dysphagia (swallowing difficulty). R35's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R35 had moderately impaired cognition. The MDS recorded she required extensive assistance of one staff with bed mobility and transfers. The MDS lacked documentation the resident received hospice services. R35's Care Plan, dated 06/10/24, recorded R35 required staff assistance with most activities of daily living (ADL) care. R35's Care Plan lacked document the resident received hospice services due to a terminal prognosis. The Progress Note, dated 11/27/23 at 03:30 PM, documented R35 did not get up for breakfast or lunch and appeared lethargic (lack of energy and mental energy, and drowsiness) and had emesis (vomit) on her bed. Staff obtained the resident's vital signs and had an oxygen reading of 93% (normal 95% to 100%,) a heart rate of 71 (normal 60-100 beats per minute), and her blood pressure was 90/43 millimeters of Mercury (mm/Hg) (normal 120/80 mm/Hg). The physician was contacted, and the resident was sent to the hospital via ambulance. The Progress Note, dated 11/29/23 at 08:28 AM, documented the resident was admitted to hospital. The Progress Notes. dated 12/04/23 at 05:33 PM, documented the resident returned to the facility and was readmitted . A review of 35's clinical record lacked evidence the resident or representative was provided the bed hold policy when she was transferred to the hospital. On 08/20/24 at 11:45 AM, R35 sat in a wheelchair in her bedroom. Certified Medication Aide (CMA) S administered the resident's medications. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided the resident or her representative, the bed hold notice when she was discharged /transferred to the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified the resident or her representative had not been provided the bed hold policy and should have been. Administrative Nurse D stated the nurse did the initial bed hold notice and that the social worker would follow up with the resident's family. The facility's Bed Hold policy, dated 06/24, documented the community staff shall inform residents upon admission and prior to a transfer for hospitalization or the therapeutic leave of the bed-hold policy. When an emergency transfer is necessary, the facility shall provide the resident and the representative with information concerning the bed hold policy per state laws as applicable. The bed hold information would include any charges that the resident may incur as well as the tie limit established by the state Medicaid plan for which the facility would reserve the resident's bed space. The facility failed to provide R35 or his representative with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. 26768 - R19's Electronic Medical Record (EMR) documented diagnoses of schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acute and pneumonia (inflammation of the lungs). The Annual Minimum Data Set (MDS), dated [DATE], documented a staff interview that indicated no memory problems. R19 was independent in decision-making and had disorganized thinking. The MDS documented R19 was independent with all activities of daily living. R19 was short of breath with any activity and used tobacco. R19 received antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality). R19's EMR documented R19 had an unplanned discharge to an inpatient psychiatric hospital from 06/10 24 to 06/14/24. R19's clinical record lacked evidence the resident was provided a copy of the bed hold notice for the above transfer. On 08/20/24 at 07:35 AM, observation revealed R19 sat at the dining table with his walker in front of him and drank an orange soda. At 07:50 AM, he stood and ambulated with his walker through the dining room to the outside exit to the smoking area. He sat on a bench outside, ate a hard-boiled egg, and drank his coffee. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided a bed hold notice to the resident or their representative when he was discharged from the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified staff should have provided a bed hold notice and stated the nurse provided the initial bed hold notice and the social worker was supposed to follow up with the resident's family or representative. The facility's Bed Hold policy, dated 06/24, documented the community staff shall inform residents upon admission and prior to a transfer for hospitalization or the therapeutic leave of the bed-hold policy. When an emergency transfer is necessary, the facility shall provide the resident and the representative with information concerning the bed hold policy per state laws as applicable. The bed hold information would include any charges that the resident may incur as well as the tie limit established by the state Medicaid plan for which the facility would reserve the resident's bed space. The facility failed to provide a bed hold notice to R19 or his representative when R19 was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the facility. 32360 - The Electronic Medical Record (EMR) for R38 had a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition and was independent with all activities of daily living (ADLs). R38 received oxygen daily and was not short of breath. R38's Care Plan, dated 05/23/24 and initiated on 07/03/17, documented R38 received oxygen therapy due to COPD and directed staff to give medications as ordered by the physician, monitor for signs and symptoms of respiratory distress and report to the physician as needed. The plan directed staff to administer oxygen via a nasal cannula (a device that gives you additional oxygen through your nose) to maintain oxygen saturation (a measure of how much oxygen the blood carried as a percentage of the maximum it could carry) above 90 % and explain the risk versus benefits should she remove her oxygen. The Progress Note, dated 06/29/24 at 09:33 AM, documented that R38 was admitted to the hospital due to abnormality of her vital signs. R38's clinical record lacked evidence the resident was provided the bed hold policy when she was transferred to the hospital. On 08/20/24 at 11:45 AM, observation revealed R38 in bed with oxygen on per nasal cannula. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided a bed hold notice to the resident when discharged to the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified staff had not provided R38 with the bed hold policy when R38 was admitted to the hospital. Administrative Nurse D stated the nurse does the initial bed hold notice and social service follows up with the resident or family. The facility's Bed Hold policy, dated 06/2024, documented the community staff shall inform residents upon admission and prior to a transfer for hospitalization or the therapeutic leave of the bed-hold policy. When an emergency transfer is necessary, the facility shall provide the resident and the representative with information concerning the bed hold policy per state laws as applicable. The bed hold information would include any charges that the resident may incur as well as the tie limit established by the state Medicaid plan for which the facility would reserve the resident's bed space. The facility failed to provide R38 with a bed hold notice which specifies the duration of the bed hold when she was transferred to the hospital. This placed R38 at risk of not being permitted to return and resume residence in the facility. 32358 - R72's Electronic Medical Record (EMR) documented R72 had a diagnosis of acute (a condition characterized by a relatively sudden onset of symptoms that are usually severe) and chronic (persisting for a long period) respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood and asthma (disorder of narrowed airways that caused wheezing and shortness of breath). R72's Quarterly Minimum Data Set (MDS), 06/24/24, documented R72 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident had shortness of breath. R72's Care Plan, revised 08/03/24, documented R72 had asthma and instructed staff to advise R72 to minimize contact with known offending allergens, administer R72 albuterol sulfate inhaler every four hours as needed (prn), and assist R72 in identifying asthma triggers and strategies for prevention. The Progress Note, dated 01/16/2024 at 05:00 PM, documented R72 was admitted to the hospital. R72's clinical record lacked evidence the resident or representative was provided notice of the facility bed hold policy when she was transferred to the hospital. On 08/19/24 at 03:21 PM, R72 sat in a chair at the front entrance of the facility. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided a bed hold notice to the resident when discharged to the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified staff had not provided R72 or her representative with the bed hold policy when R72 was admitted to the hospital. Administrative Nurse D stated the nurse does the initial bed hold notice and social service follows up with the family. The facility's Bed Hold policy, dated 06/24, documented the community staff shall inform residents upon admission and prior to a transfer for hospitalization or the therapeutic leave of the bed-hold policy. When an emergency transfer is necessary, the facility shall provide the resident and the representative with information concerning the bed hold policy per state laws as applicable. The bed hold information would include any charges that the resident may incur as well as the tie limit established by the state Medicaid plan for which the facility would reserve the resident's bed space. The facility failed to provide R72 or his representative the bed hold notice when R72 transferred to the hospital. This placed the resident and/or her representative at risk of not returning to the facility in the same room.

The facility had a census of 94 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)22, R51, and R82s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when outdated and failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:00 AM, observation of the facility's A hall treatment cart revealed the following: R22's Novolog (fast-acting insulin) flex pen was not labeled with an open or expired date. R51's Basaglar (long-acting insulin) flex pen was not labeled with an open or expired date. R82's Novolog flex pen was labeled with an open date of [DATE] (expired on [DATE], 28 days) On [DATE] at 08:05 AM, observation of the facility's A hall medication cart revealed one bottle of Vitamin D3, 30 tablets, expiration date ,d+[DATE]. On [DATE] at 08:15 AM, observation of the A hall Medication Room revealed the following: R51's Ozempic (long-acting insulin) flex pen was labeled with an open date of [DATE] (expired on [DATE], 56 days) On [DATE] at 08:30 AM, Licensed Nurse (LN) I verified the nurses were supposed to date the flex pens when opened and discard the outdated insulin and outdated stock medication. On [DATE] at 09:30 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the resident's name and discard outdated insulin and outdated stock medication. Medlineplus.gov directs open, unrefrigerated Lantus (basaglar and glargine) can be used within 28 days; after that time, they must be discarded. Medlineplus.gov directs open, unrefrigerated Ozempic can be used within 56 days: after that time, they must be discarded. The facility's Storage of Medication policy, dated ,d+[DATE], documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to discard the resident's outdated insulin flex pens, and outdated stock medication placing the residents at risk for ineffective medication.

The facility had a census of 94 residents. The sample included 19 residents with six residents reviewed for immunizations to include pneumococcal (type of bacterial infection) vaccinations. Based on record review and interview the facility failed to assess Resident (R)85, R16, R57, and R42 for eligibility to receive further pneumococcal immunizations (helps protect against serious illnesses like pneumonia- inflammation of the lungs) and failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician documented contraindication for the PCV20 pneumococcal vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - A review of the facility's current residents' Electronic Medical Records (EMR) revealed numerous residents lacked pneumococcal vaccinations or documented refusal of the vaccination. The following residents were over [AGE] years of age: R85 had no pneumococcal vaccinations or refusals documented. R85's EMR recorded a Physician Order, dated 06/15/23, that directed staff to provide pneumococcal vaccine as per facility protocol. R16 had no pneumococcal vaccinations or refusals documented. R16's EMR recorded a Physician Order, dated 02/19/24, that directed staff to provide pneumococcal vaccine as per facility protocol. R57 had no pneumococcal vaccinations or refusals documented. R57's EMR recorded a Physician Order, dated 08/14/24, that directed staff to provide pneumococcal vaccine as per facility protocol. R42 had no pneumococcal vaccinations or refusals documented. R42's EMR recorded a Physician Order, dated 04/24/24 that directed staff to provide pneumococcal vaccine as per facility protocol. On 08/20/24 at 08:50 AM, Administrative Nurse D stated she was unaware of the CDC guidelines for the PCV20 vaccine and did not know about vaccine requirements, who would be eligible, or if any of the residents would be. On 08/21/24 at 950 AM, Administrative Nurse E stated the facility used the PPSV23 pneumococcal vaccinations and verified they had not assessed if any residents were eligible for further pneumococcal vaccinations. The facility's Pneumococcal Vaccine policy, dated 09/2023, stated residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine and when indicated would be offered the vaccination unless medically contraindicated or the resident was already vaccinated. Assessment of pneumococcal vaccination status would be conducted within five working days of the resident's admission. Administration of the pneumococcal vaccination would be made in accordance with current CDC recommendations. The facility failed to assess residents for eligibility for the PCV20 vaccination, offer the vaccination, or obtain an informed declination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease.

The facility had a census of 94 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to provide written notification of facility-initiated transfers to the residents or their representatives for Resident (R)72 and R35. The facility also failed to send notification of facility-initiated discharges and transfers to the office of the State Long Term Care Ombudsman as required. This placed the residents at risk for impaired rights. Findings included: - R72's Electronic Medical Record (EMR) documented R72 had a diagnosis of acute (condition characterized by a relatively sudden onset of symptoms that are usually severe) and chronic (persisting for a long period) respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood and asthma (disorder of narrowed airways that caused wheezing and shortness of breath). R72's Quarterly Minimum Data Set (MDS), 06/24/24, documented R72 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident had shortness of breath. R72's Care Plan, revised 08/03/24, documented R72 had asthma and instructed staff to advise R72 to minimize contact with known offending allergens, administer R72 albuterol sulfate inhaler every four hours as needed, and assist R72 in identifying asthma triggers and strategies for prevention. The Progress Note, dated 01/16/2024 at 05:00 PM, documented R72 was admitted to the hospital. Review of R72's clinical record lacked evidence the resident or representative was provided written notice when she was transferred to the hospital. On 08/19/24 at 03:21PM R72 sat in a chair at the front entrance of the facility. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided a written notice of transfer/discharge to the resident when discharged to the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified staff had not provided R72 or her representative with the bed hold policy when R72 was admitted to the hospital. Administrative Nurse D stated the nurse does the initial bed hold notice and social service follows up with family. On 08/20/24 at 3:30 PM, Social Service X verified the facility had not provided R72 a written notice when R72 was transferred to the hospital. Social Services X stated she used to notify the office of the Ombudsman in the past, but approximately two years ago she was told she no longer needed to notify them since the facility had no ombudsman coverage. The facility did not provide a policy. The facility failed to provide R72 or his representative written notice regarding R72's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. 32360 - The Electronic Medical Record (EMR) for R38 had a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition and was independent with all activities of daily living (ADLs). R38 received oxygen daily and was not short of breath. R38's Care Plan, dated 05/23/24 and initiated on 07/03/17, documented R38 received oxygen therapy due to COPD and directed staff to give medications as ordered by the physician, monitor for signs and symptoms of respiratory distress and report to the physician as needed. The plan directed staff to administer oxygen via a nasal cannula (a device that gives you additional oxygen through your nose) to maintain oxygen saturation (a measure of how much oxygen the blood carried as a percentage of the maximum it could carry) above 90% and explain the risk versus benefits should she remove her oxygen. The Progress Note, dated 06/29/24 at 09:33 AM, documented R38 was admitted to the hospital due to abnormality of her vital signs. R38's clinical record lacked evidence the resident was provided a written notice of transfer/discharge as soon as practicable when she was transferred to the hospital. On 08/20/24 at 11:45 AM, observation revealed R38 in bed with oxygen on per nasal cannula. On 08/21/24 at 08:30 AM, Administrative Staff B verified the facility had not provided a written notice to the resident when she was discharged to the hospital. On 08/21/24 at 08:35 AM, Administrative Nurse D verified staff had not provided R38 with written notification for transfer when R38 was transferred to the hospital. On 08/20/24 at 3:30 PM, Social Service X verified the facility had not provided R38 a written notice when R38 was transferred to the hospital. Social Services X stated she used to notify the office of the Ombudsman in the past, but approximately two years ago she was told she no longer needed to notify them since the facility had no ombudsman coverage. Upon request a policy for notice for transfer/discharge policy was not provided by the facility. The facility failed to provide R38 written notice regarding R38's facility-initiated transfer to the hospital. This placed the resident at risk of uninformed care choices.

The facility identified a census of 90, with three residents reviewed for accidents. Based on record review and interviews, the facility failed to provide adequate supervision for Resident (R) 1, who was independent with ambulation, at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff), and had poor safety awareness. On 04/25/22 at 07:50 PM R1 refused his evening medications, this was the last time facility staff observed R1 in the facility. At 06:25 AM on 04/26/22, approximately 10 hours later, oncoming staff observed R1's window open. Upon investigation, facility staff were unable to locate R1 in the facility. Law enforcement officials located R1 20 miles from the facility at 08:00 AM on 04/26/22, 12 hours after last seen by facility staff. The facility failed to perform safety checks on R1, a high-risk resident. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of paranoid [CONDITION(S)] (characterized by predominantly positive symptoms of [CONDITION(S)] [[CONDITION(S)] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought with paranoia] with paranoia [a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking]), paranoid personality disorder (personality disorder characterized by exaggerated distrust and suspicion of other people), abnormalities of gait (manner or style of walking) and mobility, and lack of coordination. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), and verbal behaviors towards others in the assessment period. R1's behavioral symptoms put him and others at significant risk for physical illness or injury and significantly disrupted care or the living environment. No wandering behaviors occurred during the assessment period. R1 was independent with activities of daily living (ADLs). R1 received antipsychotic (class of medications used to treat [CONDITION(S)] and other mental emotional conditions) medications six days and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications one day in the seven-day lookback period. The resident used a wander/elopement alarm daily. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. R1 had delusions and hallucinations, and no wandering behavior occurred during the assessment period. R1 was independent with ADLs. R1 received antipsychotic medications seven days and antianxiety medications one day in the seven-day lookback period. The resident used a wander/elopement alarm daily. The Behavioral Symptoms Care Area Assessment (CAA) dated 11/06/21, documented R1 displayed verbal behaviors towards others one to three days during the lookback period and the behavior happened more often when R1 had delusions. R1 was known to be physically aggressive during mood changes. Staff monitored for self-isolation or changes in behavior and reported as needed. The Care Plan dated 03/12/20 documented R1 as at risk for elopement with opportunity and stated he had a history of elopement from previous facilities. The Care Plan included the resident used a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) and staff checked for proper function as scheduled. Staff considered any pattern of exit seeking need or behavior and altered resident schedules, treatment, medications or environment to manage behavior and ensure safety; encouraged participation in activity program, ensured all ancillary staff was aware of elopement potential; monitored and recorded on behavior monitoring sheet; and redirected resident when Wanderguard sounded and the resident attempted to leave . The Assessments tab of R1's EMR documented a Nursing: Wandering and Elopement Evaluation dated 03/13/22, which documented R1 as not at risk for elopement. R1's Treatment Administration Record (TAR) for April 2022 revealed staff checked placement of the resident's Wanderguard on the left wrist every shift for elopement precautions and documented staff completed the task on the day shift, evening shift, and night shift on 04/25/22. R1's TAR for April 2022 revealed behavior monitoring completed every day and night shift and staff documented R1 did not have any behaviors of paranoia, mood fluctuations, or delusional thoughts on 04/25/22. R1's Medication Administration Record (MAR) for April 2022 revealed R1 refused his scheduled medications at 08:00 PM on 04/25/22. The Notes tab of R1's EMR revealed the following: A Nursing Note on 04/24/22 at 11:36 AM documented R1 was agitated and repeatedly told the nurse he was not going to take his shot. Staff educated R1 on the schedule of his next shot and the resident became more agitated. Staff redirected R1 without success. A Social Service Note on 04/25/22 at 06:10 PM documented R1 approached Social Services X and made paranoid statements regarding the facility trying to put him in a high security prison. Social Services X attempted to assist R1 with calming techniques, R1 was not willing to listen or engage. R1 left the area and went to the front of building to sit. Staff continued to monitor and reported concerns to the Director of Nursing (DON) or Social Services X. An Alert Note on 04/26/22 at 06:15 AM documented oncoming staff alerted the nurse that a window on the right side of the building was open and the screen was off. The nurse alerted staff to see if both residents were in the room. R1 was not in the room, per staff. After completion of a head count for residents, R1 was the only one missing. Administrative Staff A was informed R1 was not present in the facility. The nurse let the DON and Assistant Director of Nursing (ADON) know that R1 was not in the building. Administrative Staff A alerted the police department that R1 was missing. At 07:25 AM, the police department arrived at the facility and all pertinent information was given to the police. Administrative Staff A received a call from the sheriff's department that R1 was found. R1 was picked up by facility staff and taken to a hospital for evaluation. A Health Status Note on 04/26/22 at 03:00 PM documented R1 admitted to the hospital for evaluation and treatment related to paranoia, delusional thoughts, and other psychiatric related diagnoses. The facility's Incident Information dated 04/26/22 recorded staff notified Administrative Staff A that R1 was missing at 06:47 AM. Staff initiated a search of the neighboring areas. Law enforcement located R1 at 08:00 AM. R1 told Administrative Staff A he did not want to take his medications, so he left. R1 stated he did not want to come back to the facility and refused to say how and when he left the facility. The report documented the windows in R1's room were tampered with and the hardware that prevented the window from opening enough to allow a person to exit the window had been removed. The Incident Information documented that upon review of the facility's camera footage, it was identified that two-hour checks were not completed on the overnight shift the night of the incident . On 04/28/22 at 01:54 PM, Administrative Nurse D stated on-coming nursing staff alerted her that the window was open. Upon completion of a headcount of residents, R1 was not in the facility. Administrative Nurse D stated that morning shift completed a search for R1 and contacted the police department. When R1 was located, Administrative Nurse D and Administrative Staff A went to his location. She stated R1 was not injured and appeared alert and oriented. Administrative Nurse D stated R1 told her he removed his Wanderguard before leaving the facility. She stated staff should have been checking on residents a minimum of every two hours and staff should make sure all residents were safe. Administrative Nurse D stated R1 somehow removed the screws from his window and opened the window. She was unsure what time he officially left the facility. She stated R1's roommate reported not seeing R1 since 09:45 PM. Administrative Nurse D stated R1 had a history of sporadically refusing his medication so his refusal that night was not suspicious to staff. She reported R1 had a history of delusions and agitation with verbal aggression, but no exit seeking behaviors and had a Wanderguard since admission due to paranoid behaviors. On 04/28/22 at 02:23 PM, Administrative Staff A stated R1's roommate reported that R1 was messing around with the window screws for several days trying to get something loose. Administrative Staff A stated the facility was aware of R1's frequent medication refusals and that R1 often had periods of refusal but would resume taking his medications. He stated that in the last two years, he did not have any firsthand reports of R1 having exit seeking behaviors apart from this incident. Administrative Staff A stated when first admitted , R1 opened a shower room window, but the window was high up and R1 would not have fit, but that was when the facility placed the Wanderguard on him. On 04/28/22 at 02:50 PM, Certified Nurse Aide (CNA) M stated R1 was last seen at 09:30 PM and 09:40 PM on 04/25/22. He stated staff checked on the residents every two hours. R1 was more agitated but was calmer in his room. On 04/28/22 at 03:20 PM, CNA N stated on 04/25/22 R1 walked by the nurses' station with a blanket over his head at 09:30 PM on his way to his room and staff rounded on residents every two hours. On 04/28/22 at 03:35 PM, Licensed Nurse (LN) G stated oncoming staff reported that a window on R1's hall was open with the screen missing. She had staff complete a head count of residents and R1 was missing. Night shift staff had left the building and was not part of the search or head count. LN G stated she called CNA O who reported she had last seen R1 in his room at 04:00 AM on 04/26/22. On 04/28/22 at 04:00 PM, Social Services X stated R1 made delusional statements on 04/25/22 and asked her a question about the prison then walked away. She stated the nurse was aware of R1's statements and staff observed him every two hours. The facility's Elopement policy documented residents requiring increased monitoring of wandering would receive supervision for a specific period identified in the care plan or physician orders. The policy listed examples of resident behavior requiring such actions as: attempted elopement, moderate or high-risk scoring on assessment and/or wandering not conducive to the safety of the resident. The policy recorded staff should promptly report any resident who tried to leave the premises or was suspected of being missing. The facility failed to provide adequate supervision for R1, who was independent with ambulation, and had poor safety awareness. On 04/25/22 at 07:50 PM R1 refused his evening medications. This was the last time facility staff observed R1 in the facility. At 06:25 AM on 04/26/22, approximately 10 hours later, oncoming staff observed R1's window was open. Upon investigation, facility staff were unable to locate R1 in the facility. Law enforcement officials located R1 20 miles from the facility at 08:00 AM on 04/26/22, 12 hours after last seen by facility staff. The facility failed to perform safety checks on R1, a high-risk resident. This deficient practice placed R1 in immediate jeopardy. On 04/26/22 the facility completed the following corrective actions: Facility wide education on the requirement to perform resident safety checks at a minimum of every two hours All residents reassessed for elopement risk. R1's window was repaired, and all windows were assessed for tampering and function. The deficient practice was cited as past noncompliance.

The facility identified a census of 95 residents. The facility identified 15 residents at risk for wandering/risk for elopement. Based on observation, interview and recorded review the facility failed to provide adequate supervision for one (#1) of three residents sampled. Resident #1, an independently mobile resident who had a history of [REDACTED]. The staff also left resident #1 at the dialysis center unattended and the resident left. This deficient practice placed resident #1 in immediate jeopardy. Findings Included: - Review of resident #1's electronic record documented the following diagnoses; major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. The quarterly Minimum (MDS) data set [DATE] recorded a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident was independent, had good balance and walks steady, no impairments or mobility devices. The Care plan dated 4/04/17 recorded the resident paced up and down the hall, to the door, refused all medication, wander guard placed on resident's left wrist, staff redirected the resident away from the front door. The Care plan revised 4/17/2017 recorded the resident was a risk for elopement with opportunity and attempting to go out the door with staff members, standing by the doors despite redirection and attempting to push on the door multiple times. On 4/17/17 the resident exited out the door. Staff re-instated the wander guard on the resident's right wrist, the staff to checked for proper placement and functioning every shift. Staff received education on the proper procedure for allowing the resident to exit the building. Staffs were to consider any pattern of exit seeking or behavior to alter the resident's schedules, treatment, medications, or environment to manage behavior and ensure safety. The resident eloped from the dialysis center on 4/19/17. The doctor was to complete a medical evaluation on his/her next visit. Staff reinstated the resident on 1:1 (one staff member monitored the resident at all times) status. Staff received education on proper procedure for 1:1 when the resident had a scheduled appointment. Staff received education on communicating resident status to transportation driver prior to leaving for appointments. The resident had a psychotherapy appointment scheduled on 4/20/17. The Interdisciplinary team would evaluate a walking program to identify a staff/resident walking program to allow resident the opportunity to spend more time outside walking in the community. The interdisciplinary team would continue to work with the resident to identify a way for him/her to see his/her family more in or outside of the facility. Staff referred the resident to Social Services and the Mental Health Director for follow-up weekly for 4 weeks. Staff would encourage independence while in the building, encourage participation in activities, and ensure that all ancillary staff aware of elopement potential. Staff explained wander guard placement to the resident and he/she verbalized understanding. Staff to follow the wander guard guidelines, monitor, and record behavior on a behavior monitoring sheet. Staff placed the resident's picture as identification in the elopement book at the front desk. Staff would provide supervision while outside, redirect the resident when wander guard sounded and resident attempted to leave the building and staff discussed residents' rights with the resident. A nursing note dated 4/4/17 at 4:23 P.M. revealed the resident was attempting to go outdoors, tried to follow staff out the doors, and paced up and down the halls. Staff redirected the resident and placed a wander guard on the resident's left wrist. A nursing note dated 4/6/17, 4/8/17, and 4/11/17 documented the resident refused to take his/her medications. A nursing note dated 4/17/17 at 9:40 A.M. revealed the resident was paced and stood by the door for 30 minutes. When an agency (staff member from an outside staffing agency) aide came in with another resident, the aide let resident #1 out the front door, no alarm sounded. Resident #1 was (in the middle of the street) unaware of the truck that was behind him/her in the street that almost hit him/her. After staff educated the resident, he/she knew the dangers that were present when he/she was alone. Staff placed the resident on 1:1 safety monitoring for elopement precautions. On 4/18/17 at 12:48 P.M. the facility reported to the state agency that activity staff U called into the facility to report he/she found resident #1 outside the facility walking down the street towards railroad tracks. Activity staff U lost visual of resident #1 did not stay with the resident due to being on his/her lunch break. Administrative nursing staff D went to the location that was reported and found resident #1 in the middle of the road without his/her walker. Administrative nursing staff D assisted resident #1 into his/her automobile, then returned to the facility. According to Accuweather.com, the temperature on Monday 4/17/17 at 10:00 A.M. was 67 degrees and fair. A nursing note dated 4/19/17 at 2:00 P.M. as a late entry: Resident #1 left the facility with the transportation driver for dialysis clinic at approximately 5:30A.M. The driver arrived at the dialysis clinic approximately 10:45 A.M. to pick up resident #1 at the scheduled time, the resident was not there. The dialysis center staff reported resident #1 had left earlier. They stated resident #1 said he/she was leaving for a bit but would be back for his/her ride when they came. The driver notified administrative nursing staff D at 10:51 A.M. Administrative nursing staff D and 2 staff members left the facility to look for resident #1. The other staff members attempted to contact family members to see if the resident had contacted them. Administrative nursing staff D arrived at the dialysis center at 11:35 A.M. and resident#1 was standing in the door, waiting for his/her ride. Administrative nursing staff D escorted resident #1 back to the facility. Staff assessed the resident and verified his/her wander guard was in place and working and reinstated the staff 1:1 monitoring of the resident. According to accuweather.com, the high temperature on Wednesday, 4/19/17 was 80 degrees. An observation on 4/25/17 at 12:00 P.M. revealed resident #1 sat in the facility's front lobby area with direct care staff O. On 4/26/17 at 7:52 A.M. interview with licensed staff H and review of the April 2017 treatment record of the wander guard, noted staff were to check placement and function. The treatment record lacked documentation on the 5th, 6th, 8th, 9th, 11th, 20th and 21st. Licensed staff H confirmed the lack of documentation. During an interview on 4/26/27 at 9:15 A.M. direct care staff P stated on 4/17/17 resident #1 was standing inside, was pacing by the door, and had been for 30 minutes before he/she left. Direct care staff P stated he/she thought the resident did not know the code. The resident had something in his/her arms. Direct care staff P stated he/she did not know who the resident was. Resident #1 was dressed very nice and he/she let resident #1 out of the door. There were several nurses at the nurses station and never tried to get resident #1 away from the door. There were several nurses sitting at the nurse's station and they never told me he/she was not to go out. He/she was not told which residents were elopement risks. During an interview on 4/26/17 at 11:19 A.M. administrative staff C stated when the nurses documented something in the behavior or intervention on the treatment record, he/she would expect the nurse to write a corresponding progress nurses' note explaining what happened. Resident #1 would cycle and if he/she did not take his/ her medications, his/her delusional and psychotic thoughts could be the reason for the increased pacing. Staff needed to protect and keep resident #1 safe. On 4/26/17 at 1:06 P.M. resident #1 stated he/she was not sure why he/she left but knew it was wrong. When he/she was at a family member's home on the weekend, he/she cut the wander guard bracelet off and brought it back as he/she knew it would sound the alarm when he/she came in the door, and left the next time. On 4/26/17 at 2:33 P.M. administrative nursing staff D stated on 4/17/17 he/she found resident #1 in the street with a yellow truck, the size of a trash truck, behind the resident that could have hit him/ her. The resident admitted that he/she was unaware of the truck. Administrative nursing staff D verified on 4/19/17 staff did not monitor the resident with 1:1 supervision at dialysis. The Elopement Policy revised January 2011 noted staff to identify residents at risk for elopement, minimize episodes of elopement, protect residents that are not capable of protecting themselves, provide the techniques and equipment to minimize safety risk, and educate staff. The facility failed to provide adequate supervision to prevent two elopements for this independently mobile resident and. On 4/17/17, Staff let the resident out the door of the facility and the resident was found walking in the middle of the road with a large truck behind him/her. On 4/19/17, the resident also left his/her dialysis treatment facility without staff supervision. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 04/26/2017 by initiating the following: 1. The regional clinical manager re-educated Director of Nursing on facility elopement guidelines 2. Validation of 100 percent (%) resident Elopement Risk Assessments were completed 3. All residents at risk of elopement with wander guards have orders in place to monitor placement and function every shift 4. Ongoing nurse education on validation of wander guard placement and functioning 5. Validated 100% of wander guard placement completed 4/25/17 6. Maintenance Director validated door lock was set at 5 seconds 7. Daily checks of all door locks and wander guard alarms were validated and continue, including on Saturday and Sunday 8. Staff education had begun on elopement guideline, and will continue 9. Education on elopement guideline would be provided to all department members at the time of hire 10. Wander guard book will be updated and maintained by Activity Director, and in his/her absence it would be reviewed daily at the Startup meeting 11. Agency orientation book was placed and will remain at nursing station and will include elopement guidelines 12. All agencies that are utilized by the facility were asked to direct their staff that all agency staff will need to find a facility nursing staff member, Director of Nursing to open exit doors for residents 13. Nurses will be educated that they will begin signing resident out when leaving the facility and in when they return 4/26/17 14. Special Resident Council will be conducted 4/26/17 to educate residents on having nurses sign them in and sign them out when leaving and returning The deficient practice remained at the scope and severity of a D.

The facility reported a census of 95 residents with 16 residents in the sample. Based on observation, interview and record review the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer and failed to ensure a resident received the necessary care and treatment to promote wound healing for one of one sampled residents reviewed for pressure ulcers. (#80) Findings Included: - Review of the resident # 80's physician order [REDACTED]. Review of resident # 80's annual MDS (Minimum Data Set) dated 6/20/2014 documented a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. The resident required extensive assistance of one staff with bed mobility and did not reject cares during the 7 day observation period. The resident had no pressure ulcers or other wounds and was at risk for developing pressure ulcers. He/she had a pressure reducing device for his/her chair and bed. Review of the ADL (Activities of Daily Living) CAA dated 7/3/2014 recorded the resident had left sided weakness and required extensive assistance with most of his/her ADLS. Review of the Pressure Ulcer CAA dated 7/3/2014 recorded the resident's skin was dry and intact with no opened areas. Review of the quarterly MDS (Minimum Data Set) dated 3/18/2015 recorded a BIMS score of 8, which indicated moderate cognitive impairment. The resident required extensive assistance of 2 or more staff with bed mobility and did not reject cares during the 7 day observation period. The resident had no pressure ulcers or other wounds and was at risk for developing pressure ulcers. He/she had a pressure reducing device for his/her chair and bed. The Braden Skin Risk Assessments dated 1/1/2014, 12/7/2014, and 3/18/2015 recorded the resident scored 13, which indicated he/she was a moderate risk for development of pressure ulcers. Review of the resident's revised care plan dated 4/8/2015 recorded the resident was at risk for non pressure and pressure related skin impairment. The care plan directed staff to provide supervision with bed mobility, inspect the resident's skin with cares, weekly skin inspections, keep the feet elevated when lying down, provide pressure reducing wheelchair cushion and pressure reduction/relieving mattress. The care plan was revised on 7/1/2015 and identified the resident had an unstageable pressure ulcer to the right heel due to required assistance with bed mobility assistance, skin desensitized, [MEDICAL CONDITION] (an abnormal condition of the blood vessels), diabetes, Braden Score of 18 or greater, obesity, absence of pedal pulse, and presence of [MEDICAL CONDITION]. The care plan directed the staff to apply skin prep to the right heel twice a day. Review of an annual nutritional assessment dated [DATE] at 10:04 A.M. recorded the resident's skin was intact and without pressure ulcers. Review of a nursing progress note dated 6/30/15 at 12:14 P.M. recorded the resident had a unstageable area with eschar to the right heel, which was tender and measured 0.5 cm (centimeters) x 0.5 cm. Appropriate treatment at this time was pressure reliving boots and skin prep to the right heel twice daily to prevent the area from opening. The practitioner would assess the resident during rounds on 7/2/2015. Review of physician's orders [REDACTED]. Elevate heels with pillows and reposition both feet while in bed to prevent skin breakdown, effective 4/16/15 Skin prep to both heels twice daily to prevent skin from opening, effective 5/16/2015 and discontinued on 6/30/2015. Skin prep to the right heel every day and evening shift twice daily to prevent the area from opening. Pressure relieving boots when in bed, effective 6/30/15. Review of May 16, 2015 TAR (Treatment Administration Record) to June 30, 2015 lacked documentation of skin prep to both heels on the evening shifts of 5/13/15, 6/16/15, 6/22/15 and on the day shifts of 6/26/15 and 6/27/15. During an observation on 06/30/2015 at 9:57 A.M. direct care staff O and P assisted the resident to his/her bed using a mechanical sit to stand lift. When staff attempted to remove the resident's right sock the resident shouted loudly it hurts. Observation revealed a pencil eraser sized circular dark area towards the right side of the resident's heel. Staff O placed one pillow under the resident's legs leaving the heels to still touch the mattress. During an observation on 06/30/2015 at 2:00:51 P.M. the resident was lying flat in his/her bed on a regular mattress with soft open heel boots on both feet. The resident's heels were not positioned in the opened area of the soft boots and the lower legs were elevated on one pillow, which was not sufficient to relieve pressure of the heels off the regular mattress. During an observation on 06/30/2015 from 2:53 P.M. to 4:52 P.M. the resident was lying on his/her back, flat in the bed on a regular mattress with soft open heel boots on both feet. The resident's heels were not positioned in the open area of the boots and laid flat against the regular mattress, despite one pillow under the resident's legs. At 4:42 P.M. direct care staff R and Q entered the resident's room to assist the resident out of bed for his/her evening meal. During an observation on 07/01/2015 at 8:47 A.M. direct care staff O and S used the sit to stand mechanical lift to transfer the resident from the wheelchair to his/her bed. The resident was dependent on staff with getting upper and lower body into the bed. Staff positioned the resident on his/her back with the head of bed at 10-15 degrees. The resident had soft open heeled boots on both feet and staff O placed one pillow under the resident's legs positioned above his/her heels. The resident then requested staff remove the boots. Staff O removed both boots and placed in his/her wheelchair. Staff failed to ask the resident why he/she did not want to wear the boots and did not provide education regarding the purpose of the boots to the resident. During an interview on 6/30/15 at 10:16 A.M. the resident reported his/her right heel hurt when staff touched the area. He/she rated the pain a 4 on a scale of 0-10, with zero being no pain and 10 being the worst pain imagined. The resident reported his/her heel hurt for more than a month. During an interview on 06/30/2015 11:04 A.M. direct care staff O reported the resident's right heel was healing for at least a month. Staff O said the resident complained of pain to the right foot, especially when transferring into the bed and taking off his/her socks. Staff O reported interventions to prevent skin breakdown included not wearing shoes. He/she was unaware of any other interventions to help with wound healing. Staff O stated he/she would let the charge nurse know if a resident complained of pain or had skin issues. Staff O stated he/she notified the charge nurse about 2 weeks ago of redness surrounding the wound on the resident's right heel. During an interview on 06/30/2015 3:34:18 .P.M. direct care staff R reported the resident has no skin breakdown or history of skin breakdown. Staff R reported interventions to prevent skin breakdown for this resident was to provide incontinence care. Staff R said if a resident had new skin issues the off going nurse would let him/her know during rounds and if the resident was independent the independent resident would let the staff know. Staff R reported he/she received an off going report from staff O on 6/30/2015 and he/she did not report any skin issues for this resident. During an interview on 07/01/2015 at 9:19 A.M. direct care staff O reported he/she did not received any instructions on how to apply the resident's soft boots or how often the resident should wear the soft boots. During an interview on 06/30/2015 at 11:27 A.M. administrative nursing staff E reported the resident had a history of [REDACTED]. Staff E reported the CNAs or nurses informed him/her if there was a wound that e/she needed to measure. He/she was unaware of any skin issues to the resident's feet at this time. Staff E assessed the resident's right foot at the surveyor's request. The resident yelled loudly that the wound hurt when the wound nurse palpated the resident's right heel. Staff E stated the wound was unstageable and believed the wound was pressure related. One pillow remained under the resident's legs, which did not prevent the heels from touching the mattress. Staff E described the wound to the resident and asked if he/she would wear soft boots. The resident was agreeable. During an interview on 07/01/2015 at 10:55 A.M. licensed nursing staff H reported the resident currently had no skin issues and no staff reported any skin issues to him/her. Staff H reported a current interventions to protect the resident's skin was to ensure the feet were elevated and positioned with pillows when in bed. Staff H reported and he/she noticed the resident wore pressure boots this morning and was not sure of the reason. During an interview on 07/01/2015 at 2:02 P.M. administrative nursing staff E reported practitioner H was phoned on 6/30/2015 and was told the resident had pain to his/her right heel and an area of eschar, believed to be caused from pressure, was discovered on the right heel. Staff E told practitioner H staff provided the resident pressure relieving boots and his/ her feet were floated and elevated. Staff E reported nursing informed him/her the resident had red and soft heels on 5/16/15. Staff E stated he/she did not assess the heels, took the nurses word and told them to elevate the heels and get an order for [REDACTED]. Staff E stated he/she expected staff O to pass the information regarding the resident's right heel wound to the oncoming direct care staff and he/she did not inform the charge nurse of the resident's wound, order for skin prep, or of the pressure relieving boots. Staff E stated he/she did not assess the soft boots on the resident and was not aware of the fit or placement. During an interview on 07/01/2015 at 2:39 P.M. administrative nursing staff D reported he/she was made aware of the resident's wound to his/her heel/ankle area on 6/30/2015. Staff D was unaware the resident experienced redness and softness to the right heel on 5/16/2015 and was not aware staff obtained an order for [REDACTED]. During an interview on 7/2/2015 at 10:44 A.M. dietary consultant DD reported he/she was unaware of the resident having red and soft heels on 5/16/2015 and was not aware of an unstageable pressure wound on the resident's right heel. He/she visited the facility once weekly and would expect nursing or the dietary manager would inform him/her given the history of diabetic ulcers and amputation history. Consultant DD reported he/she would make recommendations for a resident who experienced wounds. During a phone interview on 7/2/2015 at 12:53 P.M. physician F reported he/she was aware the resident had a history of [REDACTED]. Staff F expected the resident's heels were elevated off the mattress as the most important intervention for healing and if heels were unable to remain elevated a low air loss mattress would be the next consideration. Staff F reported practitioner H saw residents for him/her in the facility and they would meet once or twice a month to discuss residents status. Staff F reported practitioner H had not informed him/her of the resident's skin issues. Review of the facility's Prevention of Pressure Ulcer Policy dated 1/26/2015 documented residents were assessed to prevent the development of pressure ulcers. Assessment guidelines and equipment included; assessment of mobility status to include bed mobility, assessment of range of motion and limitations, appropriate bed support, heel protectors, and a turning and repositioning schedule to meet the resident's needs. The facility failed to ensure physician ordered interventions to elevate and reposition resident # 80's heels with pillows while in bed and apply skin prep twice daily were followed. The resident developed an unstageable pressure ulcer to his right heel.