Every finding on record at Elk River Health and Nursing Center of Ardmore, LL

Based on interview, record review, and facility policy review, the facility failed to ensure the prolonged use of prophylactic antibiotics was reviewed and tracked as a part of the facility's antibiotic stewardship program for 1 (Resident #9) of 5 residents sampled for medication regimen review. Findings included: A facility policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised in December 2016, indicated, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The policy also specified, All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. An admission Record revealed the facility admitted Resident #9 on 06/09/2021. According to the admission Record, the resident had a medical history that included diagnoses of personal history of urinary tract infections and encounter for prophylactic measures. Resident #9's Care Plan Report included a focus area revised on 06/22/2025 that indicated the resident was taking an antibiotic for urinary tract infection (UTI) prophylaxis and was at risk for adverse reaction, dehydration, and increased infection. Interventions directed staff to administer the medications as ordered, monitor for adverse reactions and signs and symptoms of infection and dehydration, and notify the resident's provider if observed (revised 02/19/2026). Resident #9's February 2026 Order Summary Report contained an order dated 06/11/2024 for cephalexin oral capsule 250 milligrams (mg), give 1 capsule by mouth one time a day related to personal history of urinary tract infections and encounter for prophylactic measures. A review of the facility's Infection Control Log, dated 06/01/2025 through 01/26/2026, revealed that Resident #9 was not included in the facility's review of antibiotic use in the facility. During an interview on 02/20/2026 at 8:43 AM, the DON stated that Resident #9 received a prophylactic antibiotic due to having a history of UTIs and having resistance to multiple antibiotics. The DON stated that the facility's Medical Director (MD) was involved with the facility's antibiotic stewardship program and would review antibiotic orders to determine if they were appropriate. The DON stated if the MD did not agree with a provider's order, they would call that provider and have a discussion with them regarding the order. During a telephone interview on 02/20/2026 at 9:46 AM, the MD stated that as part of the facility's antibiotic stewardship program, the facility informed her of urinalysis and culture and sensitivity results when assessing the appropriateness of antibiotic therapy for a resident with a suspected UTI. The MD stated the resident's antibiotic therapy would be based on the results, with the purpose being to ensure the resident had a UTI before putting the resident on antibiotic therapy. The MD stated Resident #9 was continued on prophylactic antibiotic therapy for several years, dating back to the previous Medical Director, due to recurrent UTIs. The MD stated she had not discussed Resident #9's prophylactic antibiotic use with the resident's provider. The MD stated they would normally review antibiotic use to ensure that the resident still required antibiotic therapy, but she was not sure if Resident #9 was reviewed for appropriate use of the prophylactic antibiotic. The MD stated that Resident #9 would be a good candidate to review because the resident had been on the prophylactic therapy for a long time. During an interview on 02/20/2026 at 10:29 AM, the facility's Infection Preventionist (IP) stated that Resident #9 was put on prophylactic antibiotic therapy by a previous Medical Director and was colonized with multidrug-resistant organisms (MDROs). The IP stated they would normally review new antibiotic orders during the monthly Quality Assurance and Performance Improvement (QAPI) meetings, but not the previously existing antibiotic orders. The IP stated she would usually go over the antibiotic orders with the providers to ensure the order met McGeer's criteria for appropriate use but was not able to state if Resident #9's prophylactic antibiotic therapy was reviewed with the resident's provider. The IP stated she did not have documentation related to reviewing the use of Resident #9's antibiotic with the resident's provider. During an interview on 02/20/2026 at 10:44 AM, the DON stated antibiotic use in the facility was discussed during monthly QAPI meetings, but they only discussed antibiotic use for that month and any other infection control trends or concerns. The DON stated that residents with prophylactic antibiotic orders were not reviewed during the QAPI meetings and stated that those residents should have been reviewed for the appropriateness of the order and continued prophylactic antibiotic use. During an interview on 02/20/2026, the Administrator (ADM) stated that he would expect the IP to discuss with the resident's provider any concerns related to antibiotic use that did not meet the criteria used by the facility.

Based on record review, interview, and facility policy review, the facility failed to ensure one resident (Resident (R)1) of 10 residents reviewed for abuse was free from verbal abuse from a staff member. Findings include: Review of the electronic medical record (EMR) under the Face Sheet tab revealed R1 was admitted to the facility on [DATE] with diagnoses including epilepsy, traumatic brain injury, and blindness. Review of the Quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/24/23 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Review of the facility's Alleged Verbal Abuse Investigation dated 03/06/23 revealed an incident of verbal abuse from an employee, Certified Nursing Assistant (CNA)2 to R1 occurred on 03/06/23 around 12:25 AM. CNA2 was immediately placed at the nurses' station and away from residents. At 1:18 AM, once all parties were informed, CNA2 was asked to leave the facility by the Director of Nursing (DON)2 until an investigation was completed. The Regional Director of Clinical Services (RDCS)2 then asked CNA2 not to return to the facility and CNA2 agreed. A Reportable Event form was completed and faxed to the authorities at 2:24 AM. As a result of the investigation, the facility did substantiate the allegation of verbal abuse. Review of the ShiftKey agency Provider Profile provided by the facility revealed CNA2 was listed as Do Not Return status. In an interview on 08/30/23 at 9:52 AM, R1 stated the staff treat her well. R1 did say a few months ago she remembered she called CNA2 an expletive name as well as other expletive things. There was no mention if CNA2 called her expletive names. In a phone interview on 08/30/23 at 10:26 AM, CNA1 who was a witness to the verbal abuse from CNA2 to R1 revealed, they were yelling back and forth. CNA1 stated CNA2 said to R1, if I'm an [expletive name], then you're a an expletive name. CNA1 revealed she informed Licensed Practical Nurse (LPN) 2 of the situation. An attempt was made to contact CNA2 via phone on 08/30/23 at 12:52 PM. When called, a recording stated the phone number had call restrictions set up and the call could not be completed. Review of the Abuse Prevention Policy & Procedure revised 03/19/19 revealed, This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences.

Based on facility policy review, medical record review, and interviews, the facility failed to update the Care Plan for 1 of 5 sampled residents (Resident #2) reviewed, which resulted in a fall with major injury. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 3/2018, revealed, .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly afterwards for potential risk for falls. Relevant risk factors must be assessed promptly .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 9/2013, revealed, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .The resident, the resident's family .are encouraged to participate in the development of and revisions to the resident's care plan . Review of the facility's policy titled, Using the Care Plan, revised 8/2006, revealed, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station .The Nurse Supervisor uses the care plan to complete the CNAs [Certified Nursing Assistant] daily/weekly work assignment sheets and/or flow sheets .CNAs are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .Changes in the resident's condition must be reported to the MDS [Minimum Data Set] Assessment Coordinator so that a review of the resident's assessment and care plan can be made . Review of the facility's policy titled, Comprehensive Assessments and the Care Delivery Process, revised 12/2016, revealed, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information .Information analysis .Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate) .Determine CAAs [Care Area Assessments] that have been triggered during completion of the MDS; and .Make decisions about care and treatment. Apply clinical reasoning to assessment information and determine the most appropriate interventions . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses which included Contracture to Left Hand, Dysphagia, and Bipolar Disorder. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #2 had long and short term memory problems and was moderately impaired with decision making. Continued review revealed she required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 2 caregivers, extensive assistance for eating of 1 caregiver and total dependence for toilet use and personal hygiene of 1 caregiver. Continued review revealed she was always incontinent of bladder and bowel. Review of the Care Plan for Resident #2 revealed, .I have Potential for falls r/t [related to] history of falls, contractures, and poor safety awareness . Interventions for fall prevention included, . 8/23/2020 scoop mattress .6/27/2022 1/4 assist bar for positioning .6/27/2022 2 person assist for bed mobility, repositioning, and incont [incontinent] care . Continued review revealed, .My skin will remain intact through next review date .9/16/2021 Assist x 2 with transfers and mobility . Review of the Resident Incident Report for Resident #2 dated 6/27/2022, revealed, .During pericare this am [morning] approxiamately [approximately] 0930, resident rolled off of bed while providing care. Resident struck head on the bottom frame of the bedside table. Laceration is noted to left side of forehead, small abrasion noted to the top of lip and inside of lip. Received orders to send resident to ER [emergency room ] per NP [Nurse Practitioner] .Post transfer to ER, resident has 9 staples to left forehead . During a phone interview on 10/10/2022 at 2:50 PM, Licensed Practical Nurse (LPN) #1 stated she was on duty the morning Resident #2 fell from her bed. She stated the resident had rolled out of the bed while CNA #1 was turning her, and she struck her head on the edge of the bedside table. During an interview on 10/10/2022 at 3:15 PM, CNA #1 stated on 6/27/2022 she was providing incontinent care for Resident #2, and she must have had her too close to the edge of the bed when she turned her. She stated the resident rolled out of the bed and hit her head on the edge of the bedside table which resulted in a large laceration to her head. During an interview on 10/10/2022 at 3:39 PM, the Regional MDS nurse confirmed the MDS assessments completed on 4/17/2022 and 6/23/2022 both coded Resident #2 as needing extensive assistance of 2 or more persons with bed mobility. She confirmed the definition of Bed Mobility, according to the MDS, was, .how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . She confirmed the Care Plan stated, .I am at risk for skin breakdown r/t contractures, impaired mobility and incontinence . Interventions included, .9/16/2021 Assist x2 with transfers and mobility . Continued review reveaIed, .I have Potential for falls r/t history of falls, contractures, and poor safety awareness . Interventions for fall prevention included, . 8/23/2020 scoop mattress .6/27/2022 1/4 assist bar for positioning .6/27/2022 2 person assist for bed mobility, repositioning, and incont [incontinent] care . The Regional MDS nurse confirmed when the MDS assessments were completed on 4/17/2022 and 6/23/2022, the Care Plan should have been updated to reflect the need for 2 person assist with bed mobility. During an interview on 10/11/2022 at 2:15 PM, the Administrator read the definition of Bed Mobility on the MDS and confirmed Resident #2 was coded as requiring extensive assistance with 2 or more caregivers. The Administrator confirmed the Care Plan should have reflected the resident required 2 or more caregivers for bed mobility, including being turned in bed, and was not when the fall occurred. The Administrator confirmed there should have been 2 persons providing incontinent care/turning Resident #2 in bed.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to protect 1 of 5 sampled residents (Resident #2) reviewed from a fall which resulted in harm. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 3/2018, revealed, .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly afterwards for potential risk for falls. Relevant risk factors must be assessed promptly .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 9/2013, revealed, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .The resident, the resident's family .are encouraged to participate in the development of and revisions to the resident's care plan . Review of the facility's policy titled, Using the Care Plan, revised 8/2006, revealed, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station .The Nurse Supervisor uses the care plan to complete the CNAs [Certified Nursing Assistant] daily/weekly work assignment sheets and/or flow sheets .CNAs are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .Changes in the resident's condition must be reported to the MDS [Minimum Data Set] Assessment Coordinator so that a review of the resident's assessment and care plan can be made . Review of the facility's policy titled, Comprehensive Assessments and the Care Delivery Process, revised 12/2016, revealed, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information .Information analysis .Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate) .Determine CAAs [Care Area Assessments] that have been triggered during completion of the MDS; and .Make decisions about care and treatment. Apply clinical reasoning to assessment information and determine the most appropriate interventions . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses which included Contracture to Left Hand, Dysphagia, and Bipolar Disorder. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #2 had long and short term memory problems and was moderately impaired with decision making. Continued review revealed she required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 2 caregivers, extensive assistance for eating of 1 caregiver and total dependence for toilet use and personal hygiene of 1 caregiver. Continued review revealed she was always incontinent of bladder and bowel. Review of the Care Plan for Resident #2 revealed, .I have Potential for falls r/t [related to] history of falls, contractures, and poor safety awareness . Interventions for fall prevention included, . 8/23/2020 scoop mattress .6/27/2022 1/4 assist bar for positioning .6/27/2022 2 person assist for bed mobility, repositioning, and incont [incontinent] care . Continued review revealed, .My skin will remain intact through next review date .9/16/2021 Assist x 2 with transfers and mobility . Review of the Resident Incident Report for Resident #2 dated 6/27/2022, revealed, .During pericare this am [morning] approxiamately [approximately] 0930, resident rolled off of bed while being provided care. Resident struck head on the bottom frame of the bedside table. Laceration is noted to left side of forehead, small abrasion noted to the top of lip and inside of lip. Received orders to send resident to ER [emergency room ] per NP [Nurse Practitioner] .Post transfer to ER, resident has 9 staples to left forehead . During a phone interview on 10/10/2022 at 11:00 AM with Family Member #1, she stated her daughter, Resident #2, used to be a resident at this facility, and sometime back in June of 2022, she was being assisted getting dressed when a CNA rolled her off of the bed. She stated Resident #2 was sent to the emergency room (ER) and received 9 stitches to a laceration on her head. She stated, The CNA just got in to big of a hurry. During a phone interview on 10/10/2022 at 2:50 PM, Licensed Practical Nurse #1 stated she was on duty the morning Resident #2 fell from her bed. She stated the CNA was changing the resident's brief in her bed. She stated she was called to the resident's room and saw the resident in the floor beside her bed with a deep laceration on her head. She stated the resident had rolled out of the bed while CNA #1 was turning her, and she struck her head on the edge of the bedside table. During an interview on 10/10/2022 at 3:15 PM, CNA #1 stated on 6/27/2022 she was providing incontinent care for Resident #2, and she must have had her too close to the edge of the bed when she turned her. She stated the resident rolled out of the bed and hit her head on the edge of the bedside table which resulted in a large laceration to her head. During an interview on 10/10/2022 at 3:39 PM, the Regional MDS nurse confirmed the MDS assessments completed on 4/17/2022 and 6/23/2022 both coded Resident #2 as needing extensive assistance of 2 or more persons with bed mobility. She confirmed the definition of Bed Mobility, according to the MDS, was, .how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . She confirmed the Care Plan stated, .I am at risk for skin breakdown r/t contractures, impaired mobility and incontinence . Interventions included, .9/16/2021 Assist x2 with transfers and mobility . Continued review reveaIed, .I have Potential for falls r/t history of falls, contractures, and poor safety awareness . Interventions for fall prevention included, . 8/23/2020 scoop mattress .6/27/2022 1/4 assist bar for positioning .6/27/2022 2 person assist for bed mobility, repositioning, and incont [incontinent] care . The Regional MDS nurse confirmed when the MDS assessments were completed on 4/17/2022 and 6/23/2022, the Care Plan should have been updated to reflect the need for 2 person assist with bed mobility. During an interview on 10/11/2022 at 2:15 PM, the Administrator read the definition of Bed Mobility on the MDS and confirmed Resident #2 was coded as requiring extensive assistance with 2 or more caregivers. The Administrator confirmed the Care Plan should have reflected the resident required 2 or more caregivers for bed mobility, including being turned in bed, and was not when the fall occurred. The Administrator confirmed there should have been 2 persons providing incontinent care/turning Resident #2 in bed.

Based on policy review, medical record review, facility documentation, observation, and interview, the facility failed to thoroughly investigate an incident of elopement for 1 of 5 sampled residents (Resident #1) reviewed for wandering and elopement. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy when Resident #1, a vulnerable resident assessed to be cognitively impaired, exited the facility through an emergency exit door and was located in a residential area approximately 1,673 feet from the facility unsupervised. The facility was unaware Resident #1 had left the facility until notified by the police. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Infection Preventionist, the Regional Nurse/Interim Director of Nursing (DON), and the Unit Manager were notified of the Immediate Jeopardy on 12/10/2020 at 7:16 PM in the Dining Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/3/2020 through 12/13/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/12/2020 at 1:40 PM, and was validated onsite by the surveyors on 12/13/2020 through 12/14/2020 through interviews, review of an Ad hoc (as needed) Quality Assurance and Performance Improvement (QAPI) meeting sign in sheet, review of in-service training records, audits, observation of an elopement drill, and staff interviews. The findings include: Review of the facility's policy titled, ABUSE PREVENTION POLICY & (and) PROCEDURE, revised on 3/19/2019, showed, .Neglect .The failure to fulfill a care-taking obligation to provide .services necessary to avoid physical harm, mental anguish .All alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan dated 12/2/2020, showed, .communication deficit related to .Hearing problem .risk for elopement as evidenced by .Verbally expressed desire to go home .Elopement risk assessment .Ensure staff is aware of resident's wander risk . Review of an Incident Note dated 12/3/2020, showed, .Resident (Resident #1) exited the facility and walked to a neighbors (neighbor's) home. Facility notified per law enforcement .resident picked up per staff in POV (private owned vehicle) and returned to facility . Review of a written statement dated 12/3/2020, showed, .Received phone call at approx. (approximately) 7:15 AM asking if we were missing a Resident .Dispatch stated he was at a house and chief (Police Chief) was there waiting. This was located on (Named Road) .Which is a Road down from the facility. Me and a Housekeeping lady (Housekeeper #2) .went and was able to convince him to get in car and brought him back. Resident (Resident #1) stated he was sorry that he was scared . This note was signed by Licensed Practical Nurse (LPN) #1. During a telephone interview on 12/9/2020 at 8:55 AM, Housekeeper #2 confirmed she and LPN #1 left the facility to go to the residence where Resident #1 had been located and returned the resident to the facility. Housekeeper #2 was asked what occurred when Resident #1 was returned to the facility. Housekeeper #2 stated, .Went back to work . Housekeeper #2 confirmed she had not been asked to write a statement regarding her knowledge of the elopement and had not received any in-services after Resident #1 eloped. During an interview on 12/9/2020 at 1:00 PM, LPN #2 confirmed she was working the day Resident #1 eloped from the facility and stated, .(Resident #1) pushed it (emergency exit door at the end of Safe Harbor Hall (quarantine unit)) right open .the fire alarm didn't go off .we were counting .and one of the tech (technicians (Certified Nursing Assistants) (CNA)) came running down the hall and said resident (Resident #1) got out .he didn't really want to be here .that night when he came in he said .to go check on his pigs .he didn't know where he was . LPN #2 stated Resident #1 was beating and knocking on the door of the residential home where he was located, stating they are trying to kill me. The family residing in the residential house called the police. Observation on the Safe Harbor Hall on 12/9/2020 at 2:38 PM, with the Administrator present, showed an emergency exit door at the end of the hall. The Administrator used a measuring device and started from the emergency exit on the Safe Harbor Hall and measured to the residential home where Resident #1 was found. It was approximately 1,673 feet from the facility. During an interview on 12/9/2020 at 3:08 PM, the Maintenance Supervisor stated that when he arrived at the facility on 12/3/2020, he was told a resident had eloped from the facility and he needed to check the doors. The Maintenance Supervisor stated, .the bottom thresh plate was moved out from the door (emergency exit door on the Safe Harbor Hall) .the bolts that hold the plates down they were all broke .it (door) should have alarmed .what I found wrong .the spring in the alarm box had come loose .therefore it (the alarm) couldn't go off .I'm glad he didn't get run over or something .it was cold that night .he was lucky he didn't get hurt .we are lucky . Review of the National Weather Service records, showed the recorded low temperature on 12/3/2020, the day of the elopement, was 37 degrees Fahrenheit and the recorded high temperature was 42 degrees Fahrenheit. The facility's completed investigation provided to the surveyors on 12/9/2020 at 3:16 PM did not include a written statement from Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #2, Housekeeper #2, Certified Nursing Assistant (CNA) #4 and CNA #6. These 5 employees were working at the time Resident #1 eloped from the facility. During a telephone interview on 12/10/2020 at 7:48 AM, LPN #1 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 had eloped and stated, .(Resident #1) wanted to get to his hogs .he was fine at first .then he started coming out wanting to go home .did it nearly all night .redirected him .then finally laid down about an hour .went to sleep .then you would hear that zipper (the zipper on the plastic door separating the Safe Harbor Hall and the rest of the facility) again and here he would come (to the non COVID Unit) .5:30-6:00 (AM) .back up again .said he needed to go .had 5 staff in the building .during the shift he was starting to go through the plastic door .he did that all night .it wore you out .at shift change .I saw him come out .went to the East Hall .I still had to finish his assessment .he would go to other doors .around 7 (7:00 PM) during shift change he had it (barrier) partially unzipped .he wanted to know when they were coming to get him .watched him go back into his room . LPN #1 was asked if any staff were on the hall with Resident #1. LPN #1 stated, No, ma'am .had tech going back and forth (from each hall) .I went to finish his admission .(Registered Nurse #1) and I chased him all night .I was sitting at the Nurse's Station .the phone rung (rang). It was the Sheriff Department and asked me if I was missing anybody .they let me know what house .next road over from us and Officer would stay till (until) we got there .I rode with housekeeper over there . LPN #1 was asked when Resident #1 had last been seen by the staff. LPN #1 stated, .I guess .10-15 minutes (prior to the elopement) . LPN #1 was asked if Resident #1 was an elopement risk. LPN #1 stated, Yes, ma'am. During an interview on 12/10/2020 at 7:50 AM, the Administrator was asked if the facility provided in-services to the staff after the elopement of Resident #1. The Administrator stated, .only with the nurses .about the door .we thought that was the problem. During an interview on 12/10/2020 at 8:20 AM, the Maintenance Supervisor stated he had not received any in-services since the elopement. During an interview on 12/10/2020 at 12:15 PM, the Administrator was asked if during the investigation the facility identified any other potential reason for Resident #1's elopement other than the door. The Administrator stated, One hundred percent believe it was the door .all of our action so far has been to repair that door .our focus .that was our root cause . The facility's investigation did not identify that Resident #1's exit-seeking behaviors and the lack of interventions by the staff could be a potential root cause of the elopement. During a telephone interview on 12/10/2020 at 2:31 PM, RN #1 confirmed she was working the 7:00 PM-7:00 AM shift the morning Resident #1 eloped and stated, .he (Resident #1) was heading down the hall straight down from (the Safe Harbor Hall) .took him back to where he belong (belonged) .(Named LPN #1) met me and I told her I found him .he kept saying wanted someone to come and get him .had only been there 1½ to 2 hours .we got in report he couldn't walk .he came out of the plastic (barrier) when I caught him . RN #1 confirmed she had not been asked to give a written statement and had only had an in-service related to checking the doors after Resident #1's elopement. During a telephone interview on 12/10/2020 at 2:53 PM, CNA #4 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 eloped. There was no documentation that she had provided a written statement related to Resident #1's elopement. During a telephone interview on 12/10/2020 at 3:15 PM, CNA #6 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 eloped. CNA #6 confirmed she had not been asked to give a written a statement related to Resident #1's elopement. She stated she had not received an in-services on wandering behavior or elopements after Resident #1's elopement. CNA #6 stated she was only given a copy of the elopement policy statement after the resident had eloped. During an interview on 12/10/2020 at 3:15 PM, the Infection Preventionist was asked if she was aware that Resident #1 was exit seeking and going to other doors in the facility attempting to get out. The Infection Preventionist stated After the fact . The Infection Preventionist was asked if she asked any staff to write a statement regarding the incident. The Infection Preventionist stated, .may have just been (LPN #1) . During an interview on 12/10/2020 at 3:34 PM, the Infection Preventionist was asked if she was aware that Resident #1 had wandering and exit seeking behaviors and was going to other doors in the facility. The Infection Preventionist stated, .After the fact .not prior to his elopement . The Infection Preventionist was asked if staff that were on duty at the time of the elopement or the shift prior to the elopement were asked to provide written statements. The Infection Preventionist stated, .may have just been (LPN #1) . The Infection Preventionist had performed the investigation due the facility did not have a DON and the Social Worker had extra extra duties. During an interview on 12/10/2020 at 4:03 PM, the Unit Manager confirmed the only in-service provided was related to checking the doors. The Unit Manager was asked if the facility had provided any in-services on elopement. The Unit Manager stated, Looking back we should have .looking back I can see that (should have provided in-services) . During an interview on 12/11/2020 at 7:49 AM, the Director of Nursing (DON) was asked what she would consider to be a thorough investigation. The DON stated, .I would have spoken to all of the people involved . The DON was asked if she would expect a written statement to be obtained from everyone involved and/or working. The DON stated, yes, Ma'am. During an interview on 12/11/2020 at 10:00 AM, the Medical Director was asked if he was aware of a resident elopement on 12/3/2020. The Medical Director stated, Yes. The Medical Director was asked if the facility should have conducted a thorough investigation of the elopement. The Medical Director stated, Yes. The Medical Director was asked if he considered interviewing 1 staff member as a thorough investigation and not providing in-services on elopement and wandering an appropriate corrective action. The Medical Director stated, No. During an interview on 12/14/2020 at 9:07 AM, the Infection Preventionist was asked if the facility conducted a thorough investigation on Resident #1's elopement. The Infection Preventionist stated, No .it's been very educational .I've learned a lot .I've never had elopement .should have been one on one (one staff member responsible for being with the resident at all times) when he started exit seeking they (staff) should have notified Nursing Administration . During an interview on 12/14/2020 at 9:20 AM, the Administrator was asked if the facility had conducted a thorough investigation of Resident #1's elopement. The Administrator stated, .I would say no .it was good, but it was too narrow . Refer to F-689 The surveyor verified the Removal Plan by: 1. On 12/3/2020-12/11/2020, the investigation was completed, and resident assessments, skin and elopement assessments were performed. The investigation was reviewed, resident assessments were reviewed, staff on all shifts were interviewed, and the DON was interviewed. 2. On 12/3/2020-12/11/2020, staff interviews were completed for all clinical staff that had worked on 12/2/2020-12/3/2020. The surveyors interviewed the clinical staff who worked 12/2/2020-12/3/2020. 3. On 12/11/2020, an investigation statement was obtained from Social Services. The Social Services employee was interviewed and the statement was reviewed. 4. On 12/3/2020-12/11/2020, a thorough investigation was completed to identify the root cause of the elopement, to identify the malfunction of an exit door alarm and an immediate intervention was not put in place by the nurse (LPN #1) when the elopement risk was identified. LPN #1 was suspended pending the investigation. The investigation was reviewed, the Administrator and DON were interviewed. 5. The Administrator was in-serviced on 12/11/2020 by the Corporate Chief Executive Officer and the Chief Clinical Officer on completing a thorough investigation and root cause analysis after a resident eloped from the facility. The Administrator was interviewed by the surveyors and he was able to verbalize the in-service he received. 6. On 12/11/2020, an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director and Members of the Interdisciplinary Team (IDT). The minutes of the Ad hoc QAPI meeting were reviewed. 7. On 12/3/2020-12/11/2020, all staff were in-serviced on exit door checks, elopement policy, all staff signing in and out on the Safe Harbor Hall, and risk cause analysis investigation. If staff members were off, on leave, or vacation, in-services were completed by telephone. The surveyors reviewed the in-services and interviewed staff on all shifts. 8. Current and ongoing completion of elopement audits, assessments, and interventions will be reviewed during clinical meetings and findings will be reported to the QAPI committee. The audits were reviewed by the surveyors and the Ad hoc QAPI meeting minutes were reviewed. 9. All incidents that could result in serious injury, serious harm, serious impairment, or death will be reviewed with the Regional Clinical Team immediately upon discovery and a thorough plan and investigation will be completed. The Administrator and DON were interviewed regarding this process. 10. All completed actions and documentation will also be shared with the Regional Clinical Team weekly for 3 weeks, then monthly for 2 and/or the facility is in 100 percent compliance. The surveyors interviewed the Administrator. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring of the effectiveness of the corrective action plan. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, facility documentation, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to a cognitively impaired resident with exit seeking behavior for 1 of 5 sampled residents (Resident #1) reviewed that were assessed to be at risk for wandering and elopement. The facility's failure resulted in Immediate Jeopardy when Resident #1, a vulnerable resident assessed to be cognitively impaired, exited through an emergency exit door and was located 1,673 feet from the facility in a residential area close to a main highway. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Infection Preventionist, the Regional Nurse/Interim Director of Nursing (DON), and the Unit Manager were notified of Immediate Jeopardy (IJ) on 12/10/2020 at 7:16 PM, in the Dining Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 12/3/2020 - 12/13/2020. The facility was previously cited F-689 on recertification surveys completed on 4/17/2018 and 2/27/2019. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/12/2020 at 1:40 PM, and was validated onsite by the surveyors on 12/13/2020 through 12/14/2020 through interviews, review of Ad hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheet, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident, revised 12/2007, showed, .Staff shall promptly report any resident who tries to leave the premises .to the Charge Nurse or Director of Nursing . Review of the facility's policy titled, Elopements, revised 8/2014, showed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .A missing resident is considered a facility-wide emergency . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan dated 12/2/2020, showed, .communication deficit related to .Hearing problem .risk for elopement as evidenced by .Verbally expressed desire to go home .Elopement risk assessment .Ensure staff is aware of resident's wander risk . Review of a Progress Note dated 12/3/2020, showed, .RESIDENT (Resident #1) ARRIVED AT APPROX (approximately) 8PM (8:00 PM) on 12/02/20 (2020) (when admitted to the facility from the hospital) BY AMBULANCE .RESIDENT WAS CONFUSED ASKING WHEN HE WAS GOING TO LEAVE .WILL CONTINUE TO MONITOR . Review of the Brief Interview of Mental Status (BIMS) assessment dated [DATE], showed Resident #1 was moderately cognitively impaired for decision making. Review of the Admission Data Collection Tool dated 12/3/2020, showed Resident #1 had a history of [REDACTED]. Review of the undated AT RISK FOR ELOPEMENT assessment showed, .paranoid, confused . Review of an Incident Note dated 12/3/2020, showed, .Confused .Resident (Resident #1) exited the facility and walked to a neighbors (neighbor's) home. Facility notified per law enforcement .resident picked up per staff in POV (private owned vehicle) and returned to facility . Observation in the resident's room on 12/9/2020 at 2:30 PM, showed Resident #1 seated in a chair next to his bed. During an interview on 12/9/2020 at 12:00 PM, the Administrator stated, .the fire exit alarm didn't sound .those (fire doors and alarms) are checked monthly . During an interview on 12/9/2020 at 1:00 PM, Licensed Practical Nurse (LPN) #2 confirmed she was working the day Resident #1 exited the building and stated, .(Resident #1) pushed it (emergency exit door at the end of Safe Harbor Hall (quarantine unit)) right open .the fire alarm didn't go off .we were counting .and one of the tech (technicians (Certified Nursing Assistants) (CNA)) came running down the hall and said resident (Resident #1) got out .we (staff) don't use that door .he didn't really want to be here .that night when he came in he said .to go check on his pigs .he didn't know where he was . LPN #2 stated Resident #1 was beating and knocking on the door of the residential home where he was located, stating they are trying to kill me. The family residing in the residential house called the police. Observation on 12/9/2020 at 2:38 PM on the Safe Harbor Hall, with the Administrator present, showed an emergency exit door at the end of the hall. The Administrator used a rolling measuring device to measure the distance from the emergency exit door to the residential home where Resident #1 was located. The surveyors observed the route Resident #1 would have taken, and Resident #1 walked on 2 different rural roads, by a wooded area close to a main highway. The distance measured was approximately 1,673 feet. During an interview on 12/9/2020 at 3:08 PM, the Maintenance Supervisor stated that when he arrived at the facility on 12/3/2020, he was told Resident #1 had eloped from the facility and he needed to check the doors. The Maintenance Supervisor stated, .the bottom thresh plate was moved out from the door (emergency exit door on the Safe Harbor Hall) .the bolts that hold the plates down they were all broke .it (door) should have alarmed .what I found wrong .the spring in the alarm box had come loose .therefore it (the alarm) couldn't go off .I check the fire doors monthly .I'm glad he didn't get run over or something .it was cold that night .he was lucky he didn't get hurt .we are lucky .I would say that door came with the building .it's pretty old .God was watching him .it (door) was just so old . During an interview on 12/9/2020 at 4:03 PM, the Infection Preventionist, stated, .I walked in and they (staff) said he (Resident #1) had eloped .one of the night shift nurses had gone to pick him up .when she got back with (Named Resident #1) .he was hungry and wanted to eat breakfast .he said he was sorry he left .he thought he need to go feed cows and pigs .I think he did do that before he came .they identified the problem with the .door .the alarm .something to do with the threshold and the alarm didn't go off .when you open the door was supposed to alarm .but it didn't .prior to his elopement we didn't keep somebody back there (on the Safe Harbor Hall) all the time . The Infection Preventionist was asked what interventions were put in place to ensure resident's safety. The Infection Preventionist stated, Nurses are going to check exterior doors . The Infection Preventionist confirmed no staff were on the Safe Harbor Hall when Resident #1 eloped from the facility. During a telephone interview on 12/10/2020 at 7:48 AM, LPN #1 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 had eloped and stated, .(Resident #1) wanted to get to his hogs .he was fine at first .then he started coming out wanting to go home .did it nearly all night .redirected him .then finally laid down about an hour .went to sleep .then you would hear that zipper (the zipper on the plastic door separating the Safe Harbor Hall and the rest of the facility) again and here he would come (to the non COVID Unit) .5:30-6:00 (AM) .back up again .said he needed to go .had 5 staff in the building .during the shift he was starting to go through the plastic door .he did that all night .it wore you out .at shift change .I saw him come out .went to the East Hall .I still had to finish his assessment .he would go to other doors .around 7 (7:00 PM) during shift change he had it (barrier) partially unzipped .he wanted to know when they were coming to get him .watched him go back into his room . LPN #1 was asked if any staff were on the hall with Resident #1. LPN #1 stated, No, ma'am .had tech going back and forth (from each hall) .I went to finish his admission .(Registered Nurse #1) and I chased him all night .I was sitting at the Nurse's Station .the phone rung (rang). It was the Sheriff Department and asked me if I was missing anybody .they let me know what house .next road over from us and Officer would stay till (until) we got there .I rode with housekeeper over there . LPN #1 was asked when Resident #1 had last been seen by the staff. LPN #1 stated, .I guess .10-15 minutes (prior to the elopement) . LPN #1 was asked if Resident #1 was an elopement risk. LPN #1 stated, Yes, ma'am. During a telephone interview on 12/10/2020 at 8:27 AM, the Police Dispatcher confirmed she received a call on 12/3/2020 from a female and stated, She (the female at the residence) said there was a man outside .didn't seem to be in his right mind walking around in their garage . The Police Dispatcher confirmed the Chief of Police was a half mile from the scene and arrived at the scene at 7:18 AM. During an interview on 12/10/2020 at 12:15 PM, the Administrator confirmed that you could not see through the plastic barrier separating the Safe Harbor Hall from the other parts of the building. The Administrator was asked if residents should be exiting the Safe Harbor Hall through the plastic barrier into other sections of the facility. The Administrator stated, No. The Administrator confirmed he was unaware that Resident #1 had unzipped the plastic barrier on the night of 12/2/2020 - 12/3/2020 and was walking down the other halls a nd was exit seeking. The Administrator confirmed the facility staff were not monitoring the plastic barrier. The Administrator was asked if the facility's investigation had identified any other potential causes for the elopement other than the door. The Administrator stated, One hundred percent believe it was the door .all of our action so far has been to repair that door .our focus .that was our root cause . The facility's investigation did not identify that Resident #1's exit-seeking behaviors and the lack of interventions by the staff could be a potential root cause of the elopement. During a telephone interview on 12/10/2020 at 3:15 PM, Certified Nursing Assistant (CNA) #6 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 eloped, and stated, .up until then (Resident #1's elopement on 12/3/2020) we haven't really had any wanderers on the COVID quarantine hall (Safe Harbor Hall) .He would unzip the plastic (barrier) himself and come out. CNA #6 was asked if any staff member was on the Safe Harbor Hall when she left to care for residents on another hall. CNA #6 stated, .No, we went and took care of them and came back as soon as we could. I did visual checks as often as I could . CNA #6 was asked if the nurses helped monitor the hall when she left the hall. CNA #6 stated, .If they weren't doing med (medication) pass, they would . During a telephone interview on 12/11/2020 at 8:53 AM, the Chief of Police stated, I got a call that a woman said a man (Resident #1) was in her garage. (The man) said someone is trying to poison him .her husband called me too .told me to get there quick there was a man in his garage .I got there .I hollered at him .he was in his pajamas, he said 'I'm about to freeze to death' .he said he was from the facility (Long Term Care Facility) .I called Police Dispatcher .to call the facility to come get him .I asked him how he got out. He (Resident #1) said I seen that door said it was unlock or open .said his sister brought him up there (Long Term Care Facility) .said she was trying to take all his things .(Resident #1) said I just want to go home .he said they (staff) keep telling me .someone is coming to get me .bless his heart he was freezing .he asked me if I had a coat .he was out there for a while . Review of the National Weather Service records, showed the recorded low temperature on 12/3/2020, the day of the elopement, was 37 degrees Fahrenheit and the recorded high temperature was 42 degrees Fahrenheit. During an interview on 12/11/2020 at 11:00 AM, the Social Worker stated, .his (Resident #1's) initial assessment that was done prior to him coming showed he was bedbound .and he had only occasional confusion .didn't show he was going to be an elopement risk .normally before COVID world .would go lay eyes on them .I left because he didn't get here till (until) 8 (8:00 PM) that night so the following morning I got the call that he had exited the building .when I got here I called his sister .she helped take care of him and I explained to her what happened .(the family member) said he has been doing that (trying to leave) at home .he does have horses and cows and he does get up in the morning and check on them and feed them .then I interviewed him (Resident #1) .I asked him why he exited the building and he said he had been in rehab (Rehabilitation) too long and he needed to go make sure his animals were being fed . The Social Worker was asked if Resident #1 was an elopement risk. The Social Worker stated, Yes, ma'am . During an interview on 12/14/2020 at 9:50 AM, the Corporate Chief Executive Officer (CEO) stated, .could have all done differently we will take this experience and learn from it . Refer to F-610. The surveyor verified the Removal Plan by: 1. On 12/3/2020, a head to toe assessment was completed on Resident #1. The surveyors reviewed the assessment. 2. On 12/3/2020, a staff member was placed on Safe Harbor Hall to provide resident supervision. On 12/11/2020 and ongoing a staff member will remain on Safe Harbor Hall if currently residents are on the hall. The surveyors observed staff members on the Safe Harbor Hall to provide supervision. 3. On 12/10/2020 staff members were in-serviced on staffing and the log documenting staff arrival or departure on the Safe Harbor Hall. If staff members were off, on leave, or vacation, in-services were completed by telephone. The surveyors reviewed the in-services and interviewed staff on all shifts. 4. On 12/3/2020, Resident #1 had a new elopement evaluation completed. The surveyors reviewed the elopement evaluation. 5. On 12/4/2020, the elopement book and Care Plans were reviewed and updated. The surveyors reviewed the elopement book and Care Plans. 6. On 12/3/2020-12/11/2020, all staff were in-serviced on exit door checks, elopement policy, requirement for to all staff sign in and out of the Safe Harbor Hall, and risk cause analysis investigation. If staff members were off, on leave, or vacation, in-services were completed by telephone. The surveyors reviewed the in-services and interviewed staff on all shifts. 7. On 12/11/2020, an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director and members of the Interdisciplinary Team (IDT). The surveyors interviewed members of the IDT and reviewed the meeting minutes. 8. On 12/11/2020, a directive was obtained from the CEO to provide staff 24 hours a day, 7 days a week on the Safe Harbor Hall when there were residents on the hall. The surveyors validated this through interviews with staff, the DON, and the Administrator. 9. On 12/10/2020-12/11/2020, all the staff were in-serviced on reporting an elopement risk. If staff members were off, on leave, or vacation, in-services were completed by telephone. The surveyors reviewed the in-service sign in sheets, and interviewed staff on all shifts. 10. Ongoing elopement drills will be completed daily for 7 days on various shifts, then weekly for 3 weeks, then monthly for 2 months or until 100% compliance is achieved. The Maintenance Director will monitor and report findings to the QAPI committee. The surveyors reviewed the documentation of the elopement drills and observed an elopement drill on 12/14/2020. 11. New staff will be in-serviced on elopement policy during their orientation and monthly for 3 months. The Director of Nursing (DON) or designee will perform the audits of the new hire orientation of training and present the results to the QAPI committee. The surveyors interviewed the DON on this process. 12. On 12/3/2020-12/11/2020, The investigation was completed, resident assessments, skin assessments, elopement assessments, and pain assessments were completed. The surveyors reviewed the investigation and assessments and interviewed staff on all shifts and the DON. 13. On 12/3/2020-12/11/2020, staff interviews were completed for all the clinical staff that had worked 12/2/2020-12/3/2020. The surveyors reviewed documentation of the interviews completed. 14. On 12/11/2020, an investigation statement from Social Services was obtained. The surveyors reviewed the statement. 15. All residents' updated elopement assessments were reviewed for current interventions and current Care Plans. The surveyors reviewed the assessments and Care Plans. 16. Ongoing completion of elopement audits, assessments, and interventions will be reviewed during clinical meetings and findings will be reported to the QAPI committee monthly. The surveyors interviewed the QAPI members. 17. Exit door alarm audits will be performed every shift for 30 days, then weekly for 3 weeks, and monthly for 2 months. The Maintenance Director will monitor to ensure compliance and report compliance data to the QAPI committee monthly. The surveyors reviewed the audits and interviewed QAPI members. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, medical record review, and interview, facility Administration failed to ensure a safe environment that provided adequate supervision to prevent an incident of elopement, failed to provide oversight to monitor and ensure the training of staff, failed to ensure a safe environment, and failed to complete a thorough investigation of elopement when Resident #1 eloped from the facility. The facility's failure to ensure a safe environment that provided supervision resulted in Immediate Jeopardy when 1 of 5 sampled residents (Resident #1) reviewed with wandering behaviors exited the building and was located at a residential home approximately 1,673 feet from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Infection Preventionist, Regional Nurse/Interim Director of Nursing (DON), and Unit Manager were notified of the Immediate Jeopardy (IJ) on 12/10/2020 at 7:16 PM, in the Dining Room. The facility was cited Immediate Jeopardy at F-610, F-689, F-835, and F-867. The facility was cited F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/3/2020 through 12/13/2020. The facility was previously cited F-689 on recertification surveys completed on 4/17/2018 and 2/27/2019. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/12/2020 at 1:40 PM, and was validated onsite by the surveyors on 12/13/2020-12/14/2020 through interviews, review of an Ad hoc (as needed) QAPI meeting sign in sheet, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's Nursing Home Administrator job description, dated 1/1/2019, showed, .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in conjunction with facility's operational budget and state and federal regulations .Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed . Review of the facility's Director of Nursing (DON) job description, dated 1/1/2019, showed, .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing service department .Assure proper handling and emergency care of residents .Assure residents with a comfortable, clean orderly and safe environment . Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 2/2020, showed, .The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements .The QAPI Committee reports directly to the Administrator . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Progress Note dated 12/3/2020, showed, .RESIDENT (Resident #1) ARRIVED AT APPROX (approximately) 8PM (8:00 PM) on 12/02/20 (2020) (when admitted to the facility from the hospital) BY AMBULANCE .RESIDENT WAS CONFUSED ASKING WHEN HE WAS GOING TO LEAVE .WILL CONTINUE TO MONITOR . Review of the Brief Interview of Mental Status (BIMS) assessment dated [DATE], showed Resident #1 was moderately cognitively impaired for decision making. Review of an Incident Note dated 12/3/2020, showed, .Confused .Resident (Resident #1) exited the facility and walked to a neighbors (neighbor's) home. Facility notified per law enforcement .resident picked up per staff in POV (private owned vehicle) and returned to facility . During an interview on 12/9/2020 at 12:49 PM, the Administrator was asked to measure the distance the resident had traveled from the facility. The Administrator confirmed they did not have a measuring device. The Administrator was asked how the facility measured the distance between the facility and the residential home where Resident #1 was located. The Administrator stated, .eye balled it . The Maintenance Supervisor purchased a measuring device on 12/9/2020 after this interview. During an interview on 12/10/2020 at 7:50 AM, the Administrator was asked if the facility had provided any education to the staff after the elopement of Resident #1. The Administrator stated , .only with the nurses .about the door .we thought that was the problem . During an interview on 12/10/2020 at 12:15 PM, the Administrator confirmed that you could not see through the plastic barrier separating the Safe Harbor Hall from the other parts of the building. The Administrator was asked if residents should be exiting the Safe Harbor Hall through the plastic barrier into other sections of the facility. The Administrator stated, No. The Administrator confirmed he was unaware that Resident #1 had unzipped the plastic barrier on the night of 12/2/2020 - 12/3/2020 and was walking down the other halls a nd was exit seeking. The Administrator confirmed the facility staff were not monitoring the plastic barrier. The Administrator was asked if the facility's investigation had identified any other potential causes for the elopement other than the door. The Administrator stated, One hundred percent believe it was the door .all of our action so far has been to repair that door .our focus .that was our root cause . The facility's investigation did not identify that Resident #1's exit-seeking behaviors and the lack of interventions by the staff could be a potential root cause of the elopement. The Administrator was asked if the facility had an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting related to the elopement. The Administrator stated, No .not for a facility repair . During an interview on 12/11/2020 at 7:49 AM, the Corporate Chief Executive Officer stated, .they (staff) dealt with him (Resident #1) trying to get out and around but they (staff) didn't exactly communicate that (to Administration for Resident #1's exit seeking behaviors) .there was a system failure . During an interview on 12/11/2020 at 2:50 PM, the Administrator confirmed he was aware the facility had been cited for Accident Hazards on recertification surveys in 2018 and 2019. During an interview on 12/14/2020 at 7:27 AM, the DON was asked what staff should be expected to do when a resident exhibits exit seeking behaviors. The DON stated, .provide the resident with a safe environment .assess the situation .one on one .then notify Nursing Administration . During an interview on 12/14/2020 at 9:07 AM, the Infection Preventionist was asked if the facility did a thorough investigation of this elopement. No .it's been very educational .I've learned a lot . The Infection Preventionist was asked what investigation she would have expected to be conducted and stated, .He should have been one on one (one staff member responsible for staying with him at all times) when he started exit seeking .they should have notified Nursing Administration . During an interview on 12/14/2020 at 9:20 AM, the Administrator was asked if the facility conducted a thorough investigation. The Administrator stated, .I would say no .the corporation staff said it was good but it was too narrow . The Administrator was asked if the elopement should have been reviewed by the QAPI Committee before 12/11/2020. The Administrator stated, .yes . The Administrator was asked, what he would have expected to be done when a resident exhibits exit seeking behavior. The Administrator stated, .the nurse should have intervened .usually one on one .she should have notified us .obviously that did not happen . Refer to F-610, F-689, and F-867. The surveyor verified the Removal Plan by: 1. Administrator was in-serviced on 12/11/2020 by the Corporate Chief Executive Officer and the Chief Clinical Officer on administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents. The Administrator was interviewed by the surveyors. 2. Exit door alarm audits will be performed every shift for 30 days, then weekly for 3 weeks, and monthly for 2 months. The Maintenance Director or designee will monitor to ensure compliance and report performance data to QAPI committee monthly for 3 months. The Exit Door Alarm Audits were reviewed by the surveyors, staff and management were interviewed regarding this process. 3. Completion of elopement audits, assessments, and interventions will be reviewed during clinical meetings and findings will be reported to the QAPI committee. The surveyors reviewed the audits, assessments, and interviewed the Administrator. 4. Elopement drills will be completed daily for 7 days on various shifts, then weekly for 3 weeks, then monthly for 2 months. The Maintenance Director will monitor the ensure compliance and will report performance data to QAPI committee monthly for 3 months. This was validated through interview with the Administrator. 5. The Administrator was in-serviced on 12/11/2020 by the Chief Executive Officer and the Chief Clinical Officer on completing a thorough investigation and root cause analysis after a resident elopement, or incidents that could place residents at further risk for potential elopement and risk for serious injury, harm, impairment, or death. This was validated through interview with the Administrator. 6. All incidents that could result in serious injury, serious harm, serious impairment, or death will be reviewed with the Regional Clinical Team immediately upon discovery and a thorough plan will be developed. This was validated through interview with the DON and Administrator. 7. All completed actions and documentation will be shared with the Regional Clinical Team weekly for 3 weeks, then monthly for 2 months and/or the facility is in 100 percent compliance. This was validated through interview with the Administrator and the DON. 8. The DON or designee will notify all members of the Regional Clinical Team of all new incidents or concerns. This was validated through interview with the DON. 9. The Administrator will address all incidents requiring investigation in the morning Interdisciplinary Team (IDT) meeting for review and analysis. This was validated through interview with the Administrator. 10. The DON or designee will review and audit all investigations for appropriate interventions and compliance to ensure resident safety. This was validated through interview with the DON. 11. A member of the Regional Clinical Team will visit the facility weekly for 4 weeks, then monthly for 2 months and/or until 100 percent compliance is achieved to review any new incidents that could result in serious injury, serious harm, serious impairment, or death to ensure compliance. All performance data will be presented monthly to the QAPI committee for 3 months and/or 100 percent compliance. This was validated through interview with the DON and Administrator. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective action plan. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to elopement, failed to thoroughly investigate an incident of elopement, failed to perform a root cause analysis of the elopement, failed to develop and implement corrective action or performance improvement activities for elopement in order to provide a safe environment for residents, and failed to ensure systems and processes were in place and consistently followed by staff and administration. This failure to ensure a safe environment resulted in Immediate Jeopardy when 1 of 5 sampled residents (Resident #1) at risk for elopement exited the building and was located at a residential home approximately 1,673 feet from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Infection Preventionist, Regional Nurse, and the Unit Manager were notified of the Immediate Jeopardy on 12/10/2020 at 7:16 PM, in the Dining Room. The facility was cited Immediate Jeopardy at F-610, F-689, F-835, and F-867. The facility was cited F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/3/2020 through 12/13/2020. The facility was previously cited F-689 on recertification surveys completed on 4/17/2018 and 2/27/2019. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/12/2020 at 1:40 PM, and was validated onsite by the surveyors on 12/13/2020-12/14/2020 through interviews, review of Ad hoc (as needed) QAPI meeting sign in sheet, review of in-service training records, audits, and observation of an elopement drill. The findings include: Review of the facility's undated policy titled, Quality Assurance Performance Improvement Process, showed, .QAPI is the program for systematic monitoring and assessment of indicators to ensure facility standards of quality are being met .Root Cause Analysis is essential to providing solutions that are effective and sustainable . Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 2/2020, showed, .This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents .The objectives of the QAPI program are to .Provide a means to measure current and potential indicators for outcomes and quality of life .Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .Establish systems through which to monitor and evaluate corrective actions .The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements .The QAPI Committee reports directly to the Administrator . Review of the facility's Nursing Home Administrator job description, dated 1/1/2019, showed, .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in conjunction with facility's operational budget and state and federal regulations .Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed . Review of the facility's Director of Nursing (DON) job description, dated 1/1/2019, showed, .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing service department .Assure proper handling and emergency care of residents .Assure residents with a comfortable, clean orderly and safe environment . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Incident Note dated 12/3/2020, showed that Resident #1 exited the building and walked to a neighbor's home. During an interview on 12/11/2020 at 7:49 AM, the Corporate Chief Executive Officer (CEO) confirmed that the incident should have been reviewed by the QAPI committee. An Ad hoc (as needed) QAPI meeting regarding the elopement of Resident #1 on 12/3/2020 was not held until Friday, 12/11/2020, after notification of the Immediate Jeopardy. During an interview on 12/11/2020 at 10:00 AM, the Medical Director confirmed Resident #1's elopement should have been addressed in a QAPI meeting. He further stated he is actively involved in the committee. During an interview on 12/14/2020 at 7:27 AM, the DON was asked if a QAPI meeting should have been conducted prior to 12/11/2020. The DON stated, .Yes. During an interview on 12/14/2020 at 9:20 AM, the Administrator was asked if a QAPI meeting should have been held prior to 12/11/2020. The Administrator stated, .Yes . Refer to F-610, F-689, and F-835. The surveyor verified the Removal Plan by: 1. The QAPI committee members met on 12/11/2020 and conducted a root cause analysis. The QAPI committee developed performance improvement plans based on identification of the root causes, and the investigation. This was validated by the surveyors through interview with the Administrator and DON. 2. On 12/11/2020, the QAPI committee members implemented an effective plan for resident safety to prevent elopement, and to monitor residents at risk of elopement. A staff in-service was conducted which included conducting a resident assessment, identification of residents at risk for elopement, and conducting a thorough investigation. This was validated through interview with the DON and Administrator, and review of the staff in-services. 3. On 12/11/2020, Performance Improvement Plans were initiated to include resident elopement, the QAPI process, and risk/incident notification. This was validated through interview with the DON and Administrator. 4. On 12/11/2020, a Performance Improvement Plan was implemented to include departmental performance data and communication, resident elopement, and risk/incident notification. This was validated through interview with the DON and Administrator. 5. The Regional Director of Clinical Services will provide oversight and monitoring of the QAPI process, departmental performance data, and communication. The Regional Director of Clinical Services will attend QAPI meetings for 3 months. This was validated through interview with the Administrator. 6. QAPI performance data will be addressed in the QAPI meetings monthly and will be evaluated by the Regional Director of Clinical Services for 3 months and/or until 100 percent compliance is achieved. This was validated through interview with the Administrator. 7. All Interdisciplinary Team (IDT) Members were in-serviced on the QAPI policy on 12/11/2020. This was validated through interview with the IDT members, DON, and Administrator. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective action plan. The facility is required to submit a Plan of Correction.

Based on review of the Center for Disease Control and Prevention (CDC) guidance, review of the Tennessee Department of Health COVID-19 County Data Snapshot, policy review, review of the facility's Employee Pocket Guide, employee in-services, time reports, employee COVID-19 screening logs, observation, and interview, the facility failed to properly follow COVID-19 policies and procedures to prevent and contain COVID 19 when 1 of 7 sampled residents (Resident #1) on the designated quarantine hall (Safe Harbor Hall), wandered off the hall and onto other halls in the facility; and failed to ensure staff COVID-19 screening logs were complete and accurate for 12 of 46 sampled staff (Registered Nurse (RN) #1, Dietary Cook #1, Certified Nursing Assistant (CNA) #2, #3, #4, #5, #6, #7, and #8, Laundry Aide #1 and #2, and Housekeeper #1) for 26 of 39 days (11/1/2020, 11/2/2020, 11/3/2020, 11/5/2020, 11/6/2020, 11/8/2020, 11/13/2020, 11/14/2020, 11/15/2020, 11/21/2020, 11/22/2020, 11/23/2020, 11/25/2020,11/26/ , 11/27/2020, 11/28/2020,11/29/2020, 11/30/2020, 12/2/2020, 12/3/2020, 12/4/2020, 12/5/2020, 12/7/2020, 12/8/2020, 12/9/2020, and 12/10/2020) of screening logs reviewed. The facility's failure had the potential to affect the 38 residents residing in the building. The findings include: Review of the CDC guidance Preparing for COVID-19 in Nursing Homes, updated 11/20/2020, showed, .Screen all HCP (Health Care Providers) at the beginning of their shift for fever and symptoms of COVID-19 .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19 .Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . Review of the Tennessee Department of Health COVID-19 County Data Snapshot, dated 12/8/2020, showed, .Over the last 7 days, the average percent positivity rate was 19.9% . Review of the Employee Reference Pocket Guide, dated 2020, showed, .Staff - daily screening - frequent temperature checks .Admissions (QUARANTINE UNIT) - require negative test prior to admission if coming from healthcare facility - placed in private room or cohorted on designated unit for 14 days on droplet & (and) contact precautions .Resident not compliant with required quarantine/isolation .Re-educate & re-direct to room .One-on-one restricting them to their room . Observation of the Safe Harbor Hall on 12/9/2020 at 11:45 AM, revealed a plastic barrier with a zipper separating a portion of the Safe Harbor Hall from the rest of the facility. During an interview on 12/9/2020 at 2:16 PM, the Infection Preventionist confirmed new admissions are placed on the hall behind the plastic barrier, referred to as the Safe Harbor Hall. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE]. Resident #1 was assessed as being moderately cognitively impaired, at risk for wandering, and had exit seeking behavior. During a telephone interview on 12/10/2020 at 7:48 AM, Licensed Practical Nurse (LPN) #1 confirmed she had worked the 7:00 PM-7:00 AM shift the morning Resident #1 had eloped and stated, .he was fine at first .then he started coming out wanting to go home .did it nearly all night .redirected him .then finally laid down about an hour .went to sleep .then you would hear that zipper (the zipper on the plastic door separating the Safe Harbor Hall and the rest of the facility) again and here he would come (to the non COVID Unit) .during the shift he was starting to go through the plastic door .he did that all night .it wore you out .he would go to other doors .(Named Staff) and I chased him all night . During a telephone interview on 12/10/2020 at 2:31 PM, RN #1 confirmed Resident #1 came out of the Safe Harbor Hall and was observed at an exit door on the East Hall. During a telephone interview on 12/10/2020 at 3:15 PM, CNA #6 confirmed she had worked the night shift the morning Resident #1 eloped. CNA #6 was asked if she thought it was acceptable for a resident to wander out of the quarantine unit and throughout the facility. CNA #6 stated, No .up until then we haven't really had any wanderers on the COVID quarantine hall (Safe Harbor Hall) .He would unzip the plastic himself and come out. During an interview on 12/10/2020 at 3:34 PM, the Infection Preventionist confirmed that residents are placed on the Safe Harbor Hall for observation and monitoring of COVID symptoms and should not wander from that area into other parts of the facility. During an interview on 12/11/2020 at 7:49 AM, the Director of Nursing (DON) confirmed residents should not wander out of the Safe Harbor Hall into the facility. Review of the facility's policy titled, Coronavirus Disease (COVID 19) - Infection Prevention and Control Measures, dated 4/2020, showed .Anyone arriving at the facility (including staff) is screened for fever and symptoms of COVID 19 . Review of the facility's Process For Screening Employees and Visitors, in-service dated 4/24/2020, showed employees were in-serviced on the screening process. Review of staff screening logs from 11/1/2020 to 12/9/2020, the Detailed Hours report, and employee schedules from 11/1/2020-12/9/2020, showed 12 of 46 sampled staff screening sheets had missing or incomplete screens, had inconsecutive dates, or were completed prior to the actual date. Information was missing or completed incorrectly on the employee screening logs as follows: The staff screening logs were individual sheets for each employee, and the employee would date and complete the screening each day when they arrived to work. Review of the screening logs showed the following screening questions: .Question #1: Have you washed your hands or used alcohol-based hand rub (ABHR) on entry . .Question #2: Do you have any of the following symptoms: Fever? Sore Throat: Cough? New Shortness of breath . .Question #3: Have you worked in facilities or locations with recognized COVID-19 cases . .Question #4: If yes to #3 (Have you worked in facilities or locations with recognized COVID-19 cases?), have you worked with a person with confirmed COVID-19? If YES, must wear PPE (Personal Protective Equipment) including mask, gown, and gloves before any resident contact . On 11/1/2020, 11/2/2020, 11/3/2020, 11/5/2020, and 11/6/2020, Dietary Cook #1 failed to answer the screening question #4. On 11/8/2020, RN #1 failed to answer the screening questions #1 and #4. Dietary Cook #1 failed to answer screening question #4. On 11/13/2020, 11/14/2020, 11/15/2020, and 11/21/2020, CNA #4 failed to answer the screening questions #3 and #4. The screening questions from 11/21/2020, were completed and signed after the screening questions dated 12/9/2020. The facility was unable to determine why the dates were not in order. On 11/22/2020, CNA #2 worked from 6:55 AM to 7:08 PM. The facility was unable to provide a screening log or temperature check for CNA #2 on this date, and CNA #4 failed to answer screening questions #3 and #4. On 11/23/2020, CNA #2 worked from 6:53 AM to 11:19 AM and CNA #3 worked from 6:36 PM to 7:36 AM. The facility was unable to provide a screening log for CNA #2 or CNA #3 for this date. On 11/25/2020, RN #1 failed to answer the screening question #4. On 11/26/2020, Housekeeper #1 failed to answer the screening questions #1 and #2. On 11/27/2020, CNA #4 failed to answer the screening questions #3 and #4. The screening questions for this date were listed on the screening log and signed after screening questions from 12/9/2020. On 11/28/2020, Laundry Aide #1 failed to answer the screening question #1. CNA #4 failed to answer the screening questions #3 and #4. On 11/29/2020, CNA #4 worked from 6:36 PM to 8:08 AM. The facility was unable to provide a screening log for CNA #4 on this date. On 11/30/2020, CNA #5 worked from 6:36 PM to 8:08 AM. The facility was unable to provide a screening log for CNA #5 on this date. On 12/2/2020, RN #1 worked from 6:58 PM to 8:10 AM. The facility was unable to provide a screening log for RN #1 for this date and CNA #4 failed to answer screening questions #3 and #4. The screening questions for this date were listed on the screening log and signed after the screening questions on 12/9/2020. On 12/3/2020, CNA #4 failed to answer screening questions #3 and #4 and screening questions for this date were listed after screening questions from 12/9/2020. On 12/4/2020, Housekeeper #1 failed to record a temperature when completing the employee screening log. On 12/5/2020, CNA #6 worked from 7:03 PM to 7:37 AM. The facility was unable to provide a screening log for CNA #6 on this date. On 12/7/2020, CNA #6 worked from 6:51 PM to 7:22 AM. The facility was unable to provide a screening log for CNA #6 for this date and CNA #4 failed to answer screening questions #3 and #4. The screening questions for this date were listed on the screening log and signed after screening questions on 12/9/2020. On 12/8/2020, CNA #4 failed to answer screening questions #3 and #4. On 12/9/2020, Laundry Aide #2 clocked in at 5:59 PM. The facility was unable to provide a screening log for Laundry Aide #2 for this date and CNA #4 failed to answer screening question #3 and #4. CNA #8 had an undated line, after her screen on 12/9/2020, with a temperature documented and question #4 was answered. The facility was unable to determine why the temperature and screening question were completed. On 12/10/2020, there was a screening listed for CNA #7 that was dated 12/11/2020 with all screening questions answered and a temperature of 97.7 recorded. During an interview on 12/9/2020 at 12:24 PM, CNA #8 confirmed staff should answer screening questions and check and record temperature on entrance to the facility. During an interview on 12/10/2020 at 10:40 AM, the Infection Preventionist confirmed that all staff should be completing employee screening logs on entrance to the facility. The Infection Preventionist was unable to determine the reason the forms were not completed, were incomplete, had dates listed that were not consecutive, or why screening questions were answered on 12/10/2020 for 12/11/2020. The Infection Preventionist confirmed that staff had been in-serviced on COVID-19 screening on 4/24/2020, and that all staff had been provided a pocket reference guide with the information on COVID-19 infection control procedures and employee screening.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when Cook #1 touched food with a contaminated glove. The facility had a census of 37 residents with 33 of those residents receiving a tray from the kitchen. The findings include: 1. The facility policy titled, Preventing Foodborne Illness - Food Handling, revised (MONTH) 2014 documented, .Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized . Observation in the Kitchen on 1/22/2020 at 4:50 PM, showed Cook #1 picked up dinner plates, bowls, tongs, plate warmers, and meal tickets with her gloved hands, served the plates, and placed a slice of bread or cornbread on each plate with the same gloved hand. During an interview conducted on 1/22/2020 at 6:00 PM, Cook #1 stated .I should use tongs for the bread .it's cross contamination .

Based on policy review, medical record review, and interview, the facility failed to ensure physician's orders were obtained for hospice services for 2 of 2 sampled residents (Resident #10 and #43) reviewed for hospice. The findings include: 1. The facility policy titled, Hospice Program, revised (MONTH) (YEAR) documented, .a member of the IDT (Interdisciplinary Team) with clinical assessment skills who is operating within the State scope of practice act .He or she is responsible for the following .Hospice physician and attending physician (if any) orders specific to each resident . 2. Review of the medical record, showed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician's Verbal Order dated 4/9/2019 documented, .Admit to (Named Nursing Center) with (Named Hospice) . The order was not signed by a physician. During an interview conducted on 1/23/2020 at 1:39 PM, the Director of Nursing (DON) confirmed the verbal order was not signed by a physician. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #10 had severe cognitive deficits, had a prognosis of less than 6 months, and received hospice care. The Physician's Order dated 8/28/2019 documented, .Do Not Resuscitate . Review of the quarterly MDS dated [DATE], showed Resident #10 received hospice services. Review of the Physician Orders from 4/9/2019 through 1/2020, showed there were no orders for hospice services. During an interview conducted on 1/23/2020 at 1:39 PM, the DON confirmed there were no hospice orders from 4/9/2019 through 1/2020 for Resident #10. 3. Review of the medical record, showed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE], showed Resident #43 had a prognosis of less than 6 months, and received hospice care. A General Note dated 9/11/2019 documented, .Resident was admitted to hospice on 9/10/19 (9/10/2019) . Review of the Physician Orders from 10/2019 through 1/2020, showed there were no orders for hospice services. During an interview conducted on 1/23/2020 at 1:39 PM, the DON confirmed there were no hospice orders from 10/2019 through 1/2020 for Resident #43.

Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 3 (Registered Nurse (RN) #1) registered nurses reviewed. The findings include: Review of the facility Personnel Action Form for RN #1, revealed a new hire date effective 4/1/19 as Director of Nursing (DON). Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards, revealed a licensure issue date of 5/1/19 license number 9 for RN #1. Interview with the Human Resource Director on 5/8/19 at 12:50 PM, in the Meeting Room, the Human Resource Director confirmed RN #1 was hired as the DON on 4/1/19 with no licensure in the State of Tennessee. Interview with RN #1 on 5/8/19 at 1:45 PM, in her office, RN #1 confirmed she had no licensure in Tennessee until 5/1/19. RN #1 was asked if she had performed any procedures prior to 5/1/19 for any resident in the facility. RN #1 stated, Yeah, I did. Started an IV (Intravenous Access) on (Named Resident) .I didn't have Tennessee license. Interview with the Administrator on 5/8/19 at 2:07 PM, in his office, the Administrator was asked if RN #1 had performed any nursing procedures prior to issuance of Tennessee license. The Administrator stated, Yes, she did an IV. She had been told not to do any procedures .

Based on policy review, medical record review and interview, the facility failed to have required discharge and transfer documentation for 1 of 1 (Resident #3) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge, Emergency policy revised (MONTH) (YEAR) documented, .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .Notify the resident's Attending Physician .Notify the receiving facility that the transfer is being made .Prepare a transfer form to send with the resident . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Departmental Notes revealed the nurse failed to document the change in Resident #3's condition, his vital signs, interventions, who was notified and an order for [REDACTED].>Review of a Departmental Notes nursing note dated 2/18/19, written by the Director of Nursing (DON) documented, .2/16/19 2:30 .resident sent to (named hospital) for eval (evaluation) and treat (treatment) . This was a late entry written 2 days after the resident was transferred to the hospital. The facility was unable to provide a physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 2/26/19 at 2:32 PM, in room [ROOM NUMBER], LPN #2 was asked if she had obtained an order to send Resident #3 to the hospital on [DATE]. LPN #2 stated, .I did not write the order . LPN #2 was asked if she sent a transfer form containing the pertinent information with Resident #3 to the hospital. LPN #2 stated, No, Ma'am. LPN #2 was asked where she documented that she called report to the receiving hospital. LPN #2 stated, I don't know that I did. LPN #2 was asked for the assessment, vital signs and interventions for Resident #2 prior to sending him to the hospital. LPN #2 stated, I couldn't find it in the computer system. Interview with the DON on 2/26/19 at 2:42 PM, in room [ROOM NUMBER], the DON was asked if the facility sends a transfer form to the hospital when a resident is transferred. The DON stated, No, Ma'am .We have never used a discharge form or transfer form. The DON was asked if an order had been written for Resident #3's transfer to the hospital. The DON stated, It was not .

Based on policy review, review of the interdisciplinary care plan meeting sign in sheets, medical record review, and interview, the facility failed to ensure residents were involved in developing the care plan and making decisions about his or her care and failed to include direct care staff in Interdisciplinary Care Planning for 2 of 2 (Residents #3 and 11) residents reviewed for care plans. The findings include: 1. The facility's Care Plans, Comprehensive Person-Centered policy, revised on 12/2016 documented, .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family .develops and implements a comprehensive, person-centered care plan for each resident .The IDT includes .A nurse aide who has responsibility for the resident .Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to .participate in the planning process .The Interdisciplinary Team must review and update the care plan .At least quarterly in conjunction with the required quarterly MDS (Minimum Data Set) assessment . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of care plan meetings following the Minimum Data Set (MDS) assessments dated 6/27/18, 11/9/18, or 2/8/19. Interview with Resident #3 on 2/25/19 at 1:54 PM in his room, Resident #3 was asked if he had been included in decisions about his care, including attending his care plan meetings. Resident #3 stated, I haven't been to one. Interview with the Social Service Director on 2/26/19 at 11:56 AM in room [ROOM NUMBER], the Social Service Director was asked if care plan meetings were conducted following the MDS assessments on 6/27/18, 11/9/18, or 2/8/19. The Social Service Director stated, No, they did not. Review of an interdisciplinary care plan meeting sign in sheet dated 9/26/18 revealed the interdisciplinary care plan meeting did not include direct care staff. Interview with the Social Service Director on 2/26/19 at 11:56 AM in room [ROOM NUMBER], the Social Service Director was asked if direct care staff such as his nurse or Certified Nursing Assistant (CNA) were included in the interdisciplinary care plan meetings. The Social Services Director stated, Very seldom . 3. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of care plan meetings following the MDS assessments dated 6/9/18 or 12/8/18. Review of an interdisciplinary care plan meeting sign in sheet dated 9/12/18 revealed the interdisciplinary care plan meeting did not include direct care staff. Interview with the Social Services Director on 2/26/19 at 11:58 AM in room [ROOM NUMBER], the Social Services Director was asked if interdisciplinary care plan meetings were held for Resident #11 after the 6/9/18 and 12/8/18 quarterly MDS assessments. The Social Services Director stated, There was no meeting . The Social Services Director further stated the direct care staff were not included in the 9/12/18 interdisciplinary care plan meeting. Interview with the MDS Coordinator on 2/26/19 at 1:44 PM in room [ROOM NUMBER], the MDS Coordinator confirmed that the interdisciplinary care plan meetings should be conducted after the MDS quarterly assessments. The MDS Coordinator was asked who should be included in the interdisciplinary care planning meetings. The MDS Coordinator stated, Should be attended by, first and foremost, the resident, the resident's family or responsible party, social services, someone from nursing, the MDS Coordinator, therapy. It's really good to have a CNA or someone who works with the resident on a day to day basis.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure safe practices were maintained when using a mechanical lift for 1 of 3 (Resident #31) residents reviewed for accident hazards. The findings include: The facility's Lifting Machine, Using a Mechanical policy revised 7/2017 documented .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #31's room on 2/25/19 at 10:51 AM, revealed Resident #31 was transferred back to bed with the use of the mechanical lift. Certified Nursing Assistant (CNA) #1 was the only staff member performing the transfer. Interview with CNA #1 on 2/26/19 at 1:57 PM in room [ROOM NUMBER], CNA #1 was asked how many people should assist with a mechanical lift transfer. CNA #1 stated, 2. CNA #1 was asked why it was necessary to have 2 staff members present for the transfer with a mechanical lift. CNA #1 stated, Safety precautions. Interview with the Director of Nursing (DON) on 2/26/19 at 4:00 PM in room [ROOM NUMBER], the DON was asked if one staff member should transfer a resident using the mechanical lift without the assistance of another staff member. The DON stated No.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses failed to perform hand hygiene between glove use during medication administration observations. The findings include: 1. The facility's Handwashing/Hand Hygiene policy documented, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .b. Before and after direct contact with residents .c. Before preparing or handling medications .1. Perform hand hygiene before applying non-sterile gloves .3. When removing gloves .4. Perform hand hygiene . Observations in Resident #34's room on 2/26/19 at 9:04 AM revealed LPN #2 entered Resident #34's room, donned gloves, applied a medication patch to Resident #34's left lower back and removed the gloves. LPN #2 did not perform hand hygiene after she removed her gloves or before donning new gloves . LPN #2 exited the room, returned to her medication cart, removed a pulse oximeter and a wrist blood pressure cuff. LPN #2 entered Resident #9's room, applied the blood pressure cuff to Resident #9's left wrist and the pulse oximeter to his finger. LPN #2 failed to perform hand hygiene after contact with Resident #34, before and after contact with Resident #9. LPN #2 exited Resident #9's room, went to the dining room to respond to an alarm on Resident #2's percutaneous endoscopic gastrostomy pump. LPN #2 failed to perform hand hygiene between contact with Resident #34, #9, and #2. Interview with LPN #2 on 2/26/19 at 4:39 PM in room [ROOM NUMBER], LPN #2 was asked when handwashing should occur. LPN #2 stated, .when they are visibly soiled .every 2 or 3 resident's room . LPN #2 was asked if she should wash her hands after the removal of her gloves and before she entered another resident's room. LPN #2 stated, .yes, very definitely . Interview with the Director of Nursing (DON) on 2/27/19 at 9:50 AM, in the DON's office, the DON was asked when nurses should wash their hands. The DON stated, All the time, before and after contact, before and after med (medication) pass .when you go into the next room . The DON was asked what staff should do after removing their gloves. The DON stated, .wash hands . The DON was asked if the nurse should enter another resident's room after administering medication to another resident without washing their hands. The DON stated, .absolutely not .

Based on policy review, observation, and interview, the facility failed to ensure the food was prepared and served under sanitary conditions as evidenced by lack of hairnets, wet nesting of pans, dirty food preparation (prep) tables, dirty oven and stove top, and a dirty ceiling vent. The facility had a census of 49, with 47 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Food Preparation and Service policy documented, .Food preparation area .5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness .Food Service/Distribution .7. Dietary staff shall wear hair restraints (hair net, hat, beard restraints .) so that hair does not contact food . 2. Observations in the kitchen on 4/15/18 at 11:00 AM, revealed a dietary cook and a dietary aide walked in the kitchen around the stove and the steam table without hair nets. Observations in the kitchen on 4/15/18 at 10:50 AM, revealed 6 long pans on the bottom of the food prep table with water dripping on the floor from wet nesting. Observations in the kitchen on 4/15/18 at 10:50 AM and 4/16/18 at 4:10 PM, revealed a tray of clean dishes and glasses stored in a dirty crate with sticky dark residue on top of the crate with the crate sitting on a dirty food prep table with scattered white residue, crumbs and rust. Observations in the kitchen on 4/15/18 at 11:00 AM, 4/16/18 at 2:30 PM, and at 4:10 PM, revealed the oven with scattered crumbs and grease and the stove top with grease splatter and dried food particles. Observations in the kitchen on 4/15/18 at 10:45 AM and 4/16/18 at 2:30 PM, revealed a dirty ceiling vent with dirt and white debris hanging from the ceiling over the food prep table. 3. Interview with the Dietary Manager on 4/16/18 at 4:14 PM, in the kitchen, the Dietary Manager was asked if it was acceptable for employees to walk in the kitchen around the stove and the steam table without a hair net. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to have wet nesting between stored pans. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to store clean dishes in a dirty crate on top of a dirty food prep table. The Dietary Manager stated, No. The Dietary Manager was asked how often were the oven and the stove top cleaned and if it was acceptable for crumbs and dried debris to be left in the oven and on the stove top. The Dietary Manager stated, .the oven and stove top should be cleaned after each meal . The Dietary Manager was asked what was in the oven and on the stove top. The Dietary Manager stated, .it doesn't look like it was cleaned after the last meal . The Dietary Manager was asked if this was acceptable. The Dietary Manager stated, No. The Dietary Manager was asked what was on the ceiling vent above the food prep table. The Dietary Manager stated, .dirt and lint . The Dietary Manager was asked if the dirty ceiling vent with white debris over the food prep table was acceptable. The Dietary Manager stated, No.

Based on policy review, medical record review and interview, the facility failed to have a signed Physicians Order for Scope of Treatment (POST) form for 1 of 25 (Resident #27) sampled residents reviewed for proper documentation of scope of treatment. The findings included: 1. The facility's Advanced Directives policy documented, .The Director of Nursing Services or designee will notify the Attending Physician of advanced directives so the appropriate orders can be documented in the resident's medical record . 2. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Retention of Urine, [MEDICAL CONDITION], Cardiac Pacemaker, [MEDICAL CONDITIONS], and Malignant Neoplasm of Prostate. The POST form on Resident #27's chart was not signed by a physician. The POST form documented, .This is a Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 4/16/18 at 3:15 PM, in the DON office, the DON was asked would you expect the resident's Advanced Directive to be signed. The DON stated, Yes ma'am.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from the accident hazards of sharps in 1 of 37 (room [ROOM NUMBER]A) resident rooms. The findings included: 1. The facility's Resident Rights/Exercise Rights policy documented, .Policy Interpretation and Implementation .k. Retain and use personal possessions to the maximum extent and space and safety permit . 2. Medical record review revealed Resident #33 (the resident residing in room [ROOM NUMBER]A) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/20/17 and revised 3/7/18 documented, .Problem/Need .Resident establishes his own goals regarding daily life choices .Resident prefers personal toiletry items in his room within his reach. This a strength for resident. In order to accomodate (accommodate) Resident and sustain his Rights and comply with State regulations, and since Resident is cognizant to use and maintain his toiletry items, he can store and maintain such items in his room as long as he keeps his door closed when he is out of his room and keeps his stop sign visible at all times .Approaches .Encourage and assist Resident in keeping personal toiletry items in a safe place so as not to cause harm to other Residents .Encourage and assist Resident in keeping his door closed when he is not in his room and encourage him to make use of his stop sign at all times . 3. Observations in room [ROOM NUMBER]A on 4/15/18 at 11:18 AM, revealed 19 disposable razors on the counter beside the sink. The resident was not in the room and the door was not shut. Observations in room [ROOM NUMBER]A on 4/15/18 at 2:15 PM, revealed 19 disposable razors on the counter beside the sink. The resident was in the bathroom, the door was shut to his room, and there was no stop sign visible. Observations in room [ROOM NUMBER]A on 4/15/18 at 4:01 PM, revealed 19 disposable razors on the counter beside the sink. The resident was not in the room and the door was not shut. Interview with the Director of Nursing (DON) on 4/15/18 at 5:00 PM, in the DON office, she was asked if razors should be left unattended in a resident's room. The DON stated, No, they should not .

Based on policy review, medical record review, observation, and interview, the facility failed to maintain complete and accurate medical records for 1 of 25 (Resident #38) sampled residents. The findings included: 1. The facility's Administering Medications policy documented, .The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MAR for the month of (MONTH) (YEAR) documented, [MEDICATION NAME] - APAP ([MEDICATION NAME]) 7.5 - 325 .TAKE 1 TABLET BY MOUTH EVERY 4 HOURS FOR PAIN . The MAR for the month of (MONTH) (YEAR) did not document [MEDICATION NAME] APAP 7.5 -325 was administered on 3/28/18 at 12 AM and 4 AM. The CONTROLLED SUBSTANCES log documented on 3/27/18 [MEDICATION NAME] APAP 7.5 - 325 was dispensed on 3/27/18 at 11 PM (1 hour prior to the scheduled time) and on 3/28/18 at 5 AM (1 hour after the scheduled time). The MAR did not document the [MEDICATION NAME] APAP 7.5 - 325 was administered. The MAR for the month of (MONTH) (YEAR) documented, [MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg (milligrams) Po (per mouth) QID (four times daily) for pain . The MAR for the month of (MONTH) (YEAR) did not document [MEDICATION NAME] 7.5/3.25 mg was administered on 4/1/18 and 4/2/18 at 12 AM and 6 AM. The CONTROLLED SUBSTANCES log documented on 3/31/18 [MEDICATION NAME] APAP 7.5 -325 was dispensed at 11 PM (1 hour prior to the scheduled time) and on 4/1/18 at 5 AM (1 hour prior to scheduled time) and on 4/1/18 at 11 PM (1 hour prior to the scheduled times) and on 4/2/18 at 6 AM. The MAR did not document [MEDICATION NAME] APAP 7.5 -325 was administered. The MAR for (MONTH) (YEAR) documented, [MEDICATION NAME] 7.5/325mg 1 tab po Q (every) 4 Hrs (hours) . The MAR for (MONTH) (YEAR) did not document [MEDICATION NAME] 7.5/325 mg was administered on 4/6/18 at 4 PM. The CONTROLLED SUBSTANCES log documented on 4/6/18 documented [MEDICATION NAME] APAP 7.5 - 325 was dispensed at 4 PM. The MAR did not document [MEDICATION NAME] APAP 7.5 -325 was administered. Interview with the Director of Nursing (DON) on 4/17/18 at 10:10 AM, at the nurses' station, the DON confirmed the [MEDICATION NAME] APAP was not signed as administered on 3/28/18, 4/1/18, 4/2/18, and 4/6/18. The DON was asked if the [MEDICATION NAME] was documented on the Controlled Substances log as dispensed would she expect it to be documented on the MAR as administered. The DON stated, Absolutely.