Every finding on record at Franklin Wellness and Rehabilitation Center

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status, obtain admission weights, monitor weights, accurately assess residents for weight loss, and implement and monitor nutritional interventions for 7 of 11 (Resident #2, #15, #17, #32, #51, #52, and #158) sampled residents reviewed for nutritional status. The facility failed to accurately assess for weight loss and implement and monitor interventions to prevent severe weight loss for Resident #17, #32, and #52. The facility's failure to identify and address severe weight loss resulted in Immediate Jeopardy for Resident #17, #32, and #52. Resident #17 experienced severe weight loss of 25.9 percent (%) in 3 months, Resident #32 experienced severe weight loss of 27.2% in 3 months, and Resident #52 experienced severe weight loss of 9.41% in one month. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Wound Care Nurse, and [NAME] President (VP) of Reimbursement were informed of the Immediate Jeopardy on 6/4/2025 at 7:49 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-692. The facility was cited at F-692 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy for F-692 began on 2/11/2025 and continued through 6/6/2025. The Immediate Jeopardy was removed on 6/7/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/6/2025 at 2:50 PM, and was validated onsite by the surveyors on 6/9/2025, through review of in-services, audits, and staff interviews conducted on all shifts. The facility's noncompliance at F-692 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's undated policy titled, Weight System, revealed Residents are weighed at admission, readmission .Weekly weights are completed for an additional 3 weeks (or longer if not stable) on the following .Admit .Readmit .Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 month or 10% in 6 months .Physician's orders .Residents are to be weighed on admission and re-admission. These weights are to be completed within 24 hours of admission/readmission. Weight (how obtained standing, lift or wheelchair) is to be recorded on the EMR [Electronic Medical Record] clinical record .Monthly weights .on all residents (including re-weighs) must be completed, and entered in the EMR, by the 10th of each month .Residents with a significant weight loss or gain (5%, 7.5% or 10% or more) will be placed on weekly weights x [times] 4 weeks or until weight is stable and no weight concerns are noted .If weight concerns .notify the RD [Registered Dietician] and continue the weekly weights until stable .All weight changes are considered unplanned unless the MD [Medical Doctor] has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring .A designated person(s) will be assigned to obtain weights for accuracy and consistency .DON .will review monthly and weekly weights prior to Weekly At-Risk Meeting .Request reweights on a resident's weekly weight if a change greater than 2% change and a residents monthly weight if greater than a 5%, 7.5% or 10% change is noted. DON .will .validate that monthly and weekly weights are recorded on the .medical record .monthly At-Risk Meeting should take place no later than the 15th of the month .Residents with significant weight loss .of 5% x 1 month will be weighed every week for four weeks .Significant weight changes .should be referred to the RD .or restorative as necessary to resolve weight concerns .Implement or request interventions as needed for residents with significant weight change at the weekly At-Risk Meeting .Care plan weight change and interventions .Review dietary intake of residents with significant weight change .Notify direct care staff of residents .DON or designee to notify the MD and resident representative of significant weight change and/or intervention in the EMR[electronic medical record .] 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, Dysphagia, Lymphedema, Peripheral Vascular Disease, and Neuropathy. Review of Resident #17's admission weight dated 8/18/2023, revealed the resident weighed 239 pounds (Lbs) using a mechanical lift. The facility failed to weigh Resident #17 on admission. Review of the Care Plan dated 7/29/2024, revealed .NAS [no added salt] diet regular texture, thin liquids .Actual Weight Loss: Related to decreased caloric intake, increased metabolic needs, or lack of appetite .Resident will have no significant weight gain or significant weight loss through next review .encourage resident to consume meals/[and]fluids .RD to eval [evaluate] with recommendations .weigh per facility protocol .6/1/2025 .at nutritional risk r/t [related to] hx [history] of dysphagia [difficulty swallowing foods or liquids], morbid obesity, therapeutic diet, Hep [Hepatitis] C [Chronic Viral Infection of Liver], liver cirrhosis [liver damage] . The care plan was not revised until 6/1/2025, and did not include interventions for weight loss. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was 14, indicating Resident #17 was cognitively intact. Additional information revealed Resident #17 weighed 245 pounds. Review of the .Weights and Vitals Summary, revealed the following: a. 1/19/2025 285.5 Lbs (Wheelchair) b. 2/14/2025 283.0 Lbs (Mechanical lift) c. 3/4/2025 264.5 Lbs (Mechanical lift) d. 4/25/2025 211.5 Lbs (Wheelchair) e. 6/2/2025 212 Lbs (Wheelchair) Review of Resident #17's meal percentages revealed 7 instances of consumed 50% or less of meals. a. 3/10/2025 breakfast 0%-25% of meal eaten b. 3/29/2025 breakfast 26%-50% of meal eaten c. 4/26/2025 breakfast 26%- 50% of meal eaten d. 5/4/2025 breakfast 26%-50% of meal eaten e. 5/4/2025 lunch 26%-50% of meal eaten f. 5/4/2025 supper 26%-50% of meal eaten g. 5/18/2025 supper 26%-50% of meal eaten Review of the progress notes for Resident #17 revealed no documentation related to the meal percentage consumption. Review of the Nutrition assessment dated [DATE], revealed .weight 283 lbs .Significant wt [weight] gain .Some wt fluctuations .Rec'd [recommend] reweigh Review of the medical record revealed no documentation the facility implemented the RD's recommendation of a re-weight for Resident #17. Review of the Nutrition/Dietary Note dated 3/25/2025, revealed Resident #17's .Weight Note .Significant wt loss 18.5# [pounds] x 18 days . Wounds non - PI [non pressure injury] RT [right] lower shin, Venous RT distal, Medial, Calf, Mid leg, DTI [deep tissue injury] to RT 1st toe and left 1st toe per [Named Wound] notes. Recommend: 1. Weekly weights x [for] 4 [weeks] r/t significant wt fluctuations 2. Liquid protein 30 ml [milliliter] BID [twice a day] x 14 days for wounds . Review of the medical record revealed no documentation the facility implemented the RD's recommendation of weekly weights x 4 weeks or Liquid Protein 30 ml BID. Review of the medical record revealed Resident #17 lost a total of 74 Lbs from 1/19/2025 to 4/25/2025, which was a severe weight loss of 25.9% in 3 months. Review of medical record revealed no nutrition or weight loss documentation for April 2025 or May 2025. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #17 was cognitively intact. Additional information included Resident #17's weight was 212 pounds. No weight loss or gain was identified on the MDS. During an interview on 6/4/2025 at 2:23 PM, the Director of Nursing (DON) confirmed meal percentages less than 50% should be addressed in the resident's progress notes. The DON was asked if the Resident (#17) was offered alternatives and was Resident (#17) experiencing weight loss. The DON stated, .I have no idea . During an interview on 6/4/2025 at 3:55 PM, the DON was asked how often weights are obtained, who makes the weight list, and how they communicated the weight loss. The DON stated .there are monthly weights, admission weights and weekly .The RD gives us a list .I don't know who the significant weights are .I don't know how she calculates that list .she emails me a list of weights and recommendations maybe monthly, then I pass it on to the Medical Director . The DON was asked what she considers weight loss. The DON stated, I cannot answer that . The DON was asked when the weight meetings were held. The DON stated, We started the weight meetings 2 weeks ago .prior to that we did not have weight meetings . The DON was asked should hospital weights be documented as admission weights. The DON stated, .No, the hospital weight is not what we are supposed to use. The DON was asked what do you consider significant weight loss. The DON stated, I cannot answer .the RD kept up with that . The DON was asked if a physician order was required for weekly weights. The DON stated Yes. The DON was asked why Resident #17 was not assessed for excessive weight loss and have documentation (of the assessment) for the weight loss. The DON stated, I do not know but she should have been assessed for weight loss and the MD [Medical Director] should have been made aware . The DON was asked why the RD's recommendations from 3/25/2025 were not documented or initiated. The DON stated, .I wasn't aware of the RD recommendations for 3/25/2025 for weekly weights for 4 weeks or the supplement .I would have notified [Named Physician] .we should have put something into place .like I said we have only had weight meetings for the past 2 weeks . The DON was asked does the facility have an efficient weight loss system in place. The DON stated No. The DON was asked who is responsible for the weight loss in the facility. The DON stated, The DON. During an interview on 6/4/2025 at 6:10 PM, the RD was asked if Resident #17 had documentation for her excessive weight loss with interventions put into place for her significant weight loss. The RD stated, I do not know, but we should have documented [the weight loss] and put something into place and the MD should have been made aware . The RD was asked what her expectations were for her weight loss recommendations, and how often does she review the weights. The RD stated, .I send an email to the DON .I would expect the DON to inform the MD and to put my recommendation in immediately and if they don't agree with the recommendation, they could just talk to me .I look at the weights weekly in [Named EMR] . The RD was asked how she follows up on her recommendations. The RD stated, I try to follow up weekly, but we only started weight meetings 2 weeks ago . The RD was asked if she documented Resident #17's significant weight loss for April or May 2025. The RD stated, No. The RD was asked if the facility weight loss program was working. The RD stated, No, it isn't . During an interview on 6/5/2025 at 9:30 AM, the MD was asked if she was notified of Resident #17's significant weight loss. The MD stated, No, I wasn't aware. The MD was asked what's your expectation of the facility with weights and nutrition monitoring. The MD stated, .to follow their policy and identify the weight loss, notify me of significant weight loss, and document the patient's medical condition in the electronic medical records .their progress notes are very limited, if you do it, document it . I'm not notified of a lot of different things . 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety and Dysphasia. Review of the Care plan dated 2/10/2025, revealed .Actual Weight Loss: Related to decreased caloric intake, increased metabolic needs, or lack of appetite .Date Initiated .2/21/2025 .Interventions .Diet per md order .medication per md order .RD to eval [evaluate] with recommendations . Review of the .Nutritional Assessment, dated 2/11/2025, revealed .Weight: 141.5 .Recommend [named nutritional supplement] 90 ml TID [three times a day] . Review of the signed Order Review History Report, revealed . [named nutritional supplement] three times a day .Order Date 02/21/2025 . The order was not written for the nutritional supplement until 10 days after the RD recommendation. Review of the Nutrition/Dietary Note, dated 4/7/2025, revealed . Significant wt loss -25# (-17.7%) x 21 days .Recommend new weight to verify . Review of the medical record revealed no weights were documented for April 2025. Review of the .Nutritional Assessment, dated 5/16/2025, revealed .Weight: 102.5 . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 which indicated Resident #32 was severely cognitively impaired. Additional information included Resident #32's weight was103 pounds, with a weight loss of 5% or more in the last month or 10% or more in 6 months, and Resident #32 was not on a physician-prescribed weight loss regimen. Review of the .Weights and Vitals Summary, dated June 3, 2025, revealed: a. 2/11/2025 141.5 pounds (Lbs) (Hospital weight) b. 3/4/2025 116.5 Lbs (Standing) c. 5/1/2025 102.5 Lbs (Wheelchair) d. 5/12/2025 102.5 Lbs (Wheelchair) e. 5/21/2025 102.9 Lbs (Wheelchair) Weekly weights were not documented for the week of 2/17/2025, 2/24/2025 and 3/10/2025. Review of the medical record revealed Resident #32 lost a total of 25 Lbs from 2/11/2025 to 3/4/2025, which was a severe weight loss of 17.6% in less than 1 month. Review of the medical record revealed Resident #32 lost a total of 14 Lbs from 3/4/2025 to 5/1/2025, which was a severe weight loss of 12% in less than 2 months. Review of the medical record revealed Resident #32 lost a total of 38.6 Lbs in 3 months, which was a severe weight loss of 27.2% and no additional weight loss interventions were implemented after the nutritional supplement was begun on 2/21/2025. The facility failed to obtain an admission weight, weekly weights, and monthly weights, failed to reweigh Resident #32 per the RD recommendation, failed to administer Med Pass until 10 days after the RD recommendation, and failed to implement nutritional interventions in March for the significant weight loss. During an interview on 6/4/2025 at 5:12 PM, the DON was asked if staff should use a hospital weight on admission. The DON stated, No. The DON was asked if there was a weight for Resident #32 for April 2025. The DON stated, No. The DON was asked if they would have noted the weight loss sooner if there would have been an April Weight. The DON stated, Yes. During an interview on 6/4/2025 at 6:59 PM, the RD stated, I put her [Resident #32] on weekly weights on 5/12/2025, assistance with meals, and [named nutritional supplement] with meals .the MD and staff are not really looking at recommendations .they should not use the hospital weight . During an interview on 6/9/2025 at 10:59 AM, the Administrator was asked if she was aware of the significant weight loss (Resident #32) at the facility. She stated, I didn't know it was significant . I didn't identify the weight loss as an issue. I was listening to the DON . 4. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, and Respiratory Failure with Hypoxia. Review of the care plan dated 4/13/2025, revealed .Resident at nutrition risk .Date Initiated 4/14/2025 .Diet per md order Date Initialed 5/2/2025 . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #52 was moderately cognitively impaired. Resident #52 required partial to moderate assistance with meals and weighed 152 pounds. Review of the .Weights and Vitals Summary, revealed: a. 4/14/2025 152.9 Lbs (Hospital weight) b. 5/1/2025 138 Lbs (Wheelchair) c. 5/14/2025 138.5 Lbs (Wheelchair) d. 5/21/2025 138.9 Lbs (Wheelchair) Weekly weights were not documented for the week of 4/21/2025 and the week of 5/5/2025. Review of the medical record revealed Resident #52 lost a total of 14.4 Lbs from 4/14/2025 to 5/14/2025, which was a severe weight loss of 9.41% in one month. The facility failed to implement nutritional interventions after Resident #52 experienced severe weight loss one month after admission to the facility. Observation in the Resident's room on 6/3/2025 at 7:52 AM, revealed Resident #52's breakfast on the over bed table next to the bed, the meal was not touched, and there was no one to assist the Resident with the meal. During an interview on 6/4/2025 at 5:12 PM, the DON was asked should a hospital weight be used as an admission weight. The DON stated, .they [facility staff] should not use a hospital weight and should be weighed on admission at the facility . The DON was asked, .Should Resident #52 have been weighed in April. The DON stated, Yes The DON stated that monthly weights are done the first week of the month and if a resident has weight loss it is done weekly. The DON was asked if she was aware Resident #52 was a significant weight loss. She stated, .152.9 [Lbs] on admit and 138 pounds . During an interview on 6/4/2025 at 6:10 PM, the RD stated that she put Resident #32 on weekly weights on 5/12/2025. During an interview on 6/4/2025 at 6:52 PM, the RD stated she recommended fortified foods for weight loss on 5/19/2025. The RD confirmed that her recommendation from 5/19/2025 had not been implemented. Review of the medical record revealed the RD's recommendation for fortified foods was not documented in the medical record and was not implemented according to the RD's recommendation. During an interview in the conference room on 6/5/2025, the MD confirmed that a hospital weight was not an accurate weight to use for an admission weight, she was not notified of the Resident's (#52) weight loss, there should have been a note or new orders for weight loss, and (Resident #52) should have weekly weights. The MD was asked what her expectations on weights were and how should staff follow up with weights. The MD stated .Follow the policy and notify me and if they see significant change either loss or gain, tell me what the plan is . 5. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Injury Cervical Spinal Cord, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #2 was cognitively intact, and weighed 204 pounds. Review of the .Weights and Vitals Summary, dated 9/2/2024, revealed Resident #2's documented weight on 9/2/2024 was 204 Lbs (Hospital weight). On 9/12/2024 Resident #2 weighed 203.7 Lbs (Mechanical Lift). Review of the Nutrition assessment dated [DATE], revealed .Most Recent Weight .204.0 [Lbs] .Date 9/2/2024 .Diet Type .Regular .based on hospital record 204# [pounds] .Obtain new wt [weight] measure . The facility failed to obtain an admission weight until 9/12/2024, 14 days after admission on [DATE]. 6. Review of the medical records revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of Resident #15's admissions and .Weights and Vitals Summary, included the following: a. 8/20/2024 159 Lbs. Resident #15 was readmitted following a hospitalization on 8/16/2024 and weight was not obtained until 8/20/2024. b. 10/11/2024 114.4 Lbs. Resident #15 was readmitted following a hospitalization on 9/28/2024 and weight was not obtained until 10/11/2024. c. 3/6/2025 114.4 Lbs. Resident #15 was readmitted following a hospitalization on 3/2/2025 and weight was not obtained until 3/6/2025. d. readmission following hospitalization on 3/13/2025 and no weight was obtained. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #15 was cognitively intact. Additional information included Resident #15 had a feeding tube, and total calories received through parenteral, or tube feeding, was 51% or more. 7. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Fracture of the Left Femur, Neurologic Neglect Syndrome, and Dysphagia. Review of the .Weights and Vitals Summary, for Resident #51, revealed the following: a. admission date was 3/27/2025 and no weight was obtained b. 4/21/2025 161.7 Lbs (Hospital weight) c. 5/1/2025 1st weight obtained while in the facility was 143.8 Lbs (mechanical lift) d. 5/20/2025 132.8 Lbs (mechanical lift) Review of the Nutritional Assessment for Resident #51 dated 4/21/2025, revealed .Weight 161.7 .Hospital weight . Review of the RD Progress Note for Resident #51 dated 4/21/2025, revealed .Hospital weight 161.7 .new weight needed . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #51 was severely cognitively impaired. Resident #51 needed partial to moderate assistance with meals. Resident #51's weight on the admission assessment was 143 pounds. Review of the medical record revealed Resident #51 was not weighed on admission to the facility. Resident #51 went out to the hospital on 4/3/2025 and was not weighed on readmission to the facility on 4/18/2025. Resident #51's first weight in the facility was 5/21/2025. During an interview on 6/4/2025 at 3:53 PM, the DON confirmed Resident #51 should have been weighed on admission and readmission from the hospital. 8. Review of the medical record revealed Resident #158 was admitted to the facility on [DATE], with diagnoses including Stage 2 Sacrum Pressure Ulcer, Metabolic Encephalopathy, and Urinary Tract Infection. Review of the .Weights and Vital Summary, dated 5/27/2025, revealed Resident #158 weighed 112.4 Lbs and the weight was obtained in a wheelchair. The facility failed to obtain an admission weight on Resident #158 until 5/27/2025, 3 days after admission on [DATE]. Review of the Nutrition assessment dated [DATE], revealed .Most Recent Weight .112.4 .Date 5/27/2025 .Will monitor nutrition parameters and f/u [follow up] as indicated . An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/6/2025 at 2:50 PM, and was validated onsite by the surveyors on 6/9/2025, through review of in-services, audits, and staff interviews conducted on all shifts. 1. A comprehensive facility-wide audit of all residents was conducted on 6/5/2025 with the Interdisciplinary (IDT) At Risk Team. All residents with greater than (>) 5% weight loss in 30 days, 7.5% weight loss in 90 days, or >10% weight loss in 180 days were flagged. Eleven residents triggered for significant weight loss. Of those 11 residents, 7 residents had previously been identified and had interventions implemented. One resident had a desired weight loss (as documented by RD). Three new weight losses were identified. All three are expected weight losses. One resident lost due to improvement of significant edema and diuretic orders. The other two residents are currently receiving end of life services including hospice services. Identified residents were reviewed by the IDT team. Appropriate interventions were initiated for each identified at-risk resident, including weekly weights, labs, supplements, medication changes, physician notifications and RP notification as indicated. The surveyors confirmed this by record review and interview. 2. On 5/5/2025, the IDT Team identified that the weight scale was not weighing accurately. A PIP (Performance Improvement Plan) was put in place and the scale was recalibrated. On 5/22/2025 the IDT team determined the weights were still inaccurate. The IDT Team ordered a new weight scale on 5/22/2025. The new scale was delivered to the facility on 6/2/2025. Between 6/2/2025 and 6/5/2025 all residents were re-weighed for accurate weights. Accurate weights were reviewed by the IDT At Risk Team on 6/4/2025 and 6/5/2025. Policy Revision: Facility's weight monitoring and nutrition policy were reviewed with no changes made. The processes were reviewed, and the following changes were made: Two CNAs (Certified Nursing Assistants) were identified to obtain all weekly and monthly weights on Mondays and Tuesdays. Weights will be completed on new admissions upon admission and readmissions. Hospital weights will not be utilized. i. DON and RD will review the monthly and weekly weights prior to the weekly weight meeting on Wednesdays. ii. IDT At Risk Meeting will be conducted every Wednesday Staff Education: iii. On 6/4/2025 the Regional Director of Clinical Services conducted an inservice with the IDT Team to educate them on weight loss policy/processes to include admission/readmission weight process, assessing nutritional status and implementing pertinent nutritional interventions. The surveyors confirmed this by record review and interview. On 6/4/2025 all On Duty Licensed Nurses were educated by the Interim Assistant Director of Nursing regarding admission and readmission weight process. All off duty, to include PRN (as needed) or Agency, Licensed Nurses will receive this education prior to beginning their next shift. Newly hired Licensed Nurses will receive this education prior to working a shift. On 6/4/2025 at 9:30 PM, the Ad hoc (for a particular purpose) QAPI (Quality Assurance and Performance Improvement) Committee along with the Governing body held a meeting to include the Administrator, Director of Nursing, Medical Director (via Telephone), Interim Assistant Director of Nursing, RD, Regional Director of Clinical Services, VP (Vice-President) of Reimbursement (MDS), and Chief Operating Officer (COO) (Governing Body) to discuss the notification of the Immediate Jeopardy, review all findings, develop an action plan and monitoring. All were in agreement with the Plan of Correction. The Surveyors confirmed this by record review and interview. QA Audits: DON or Interim ADON will review all new admission/readmissions weight records 3 times weekly x 3 weeks, then weekly for 4 weeks, then monthly for 3 months. Started 6/9/2025. Surveyors confirmed this by interview. The IDT will meet weekly on Wednesdays for review of admission/readmission weight process, assessing nutritional status and implementing pertinent nutritional interventions for identified residents. The Regional Director of Clinical Services and/or VP of Nutritional Services will be in attendance of IDT meetings weekly x 2, then monthly x 3 to ensure compliance. Meeting set for 6/11/2025. Surveyors confirmed this by interview The Maintenance Supervisor will ensure the scales are calibrated quarterly or more often if the IDT Team identifies possible inconsistencies. Reports will be submitted to the QAPI Committee quarterly for review. New scale will begin when due. Surveyors confirmed this by interview

Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to ensure 1 of 3 (Resident #10) sampled residents reviewed for accident hazards received adequate supervision to prevent elopement (a situation where a resident leaves the premises or safe area without necessary supervision). On 4/27/2024, at approximately 1:00 PM, Resident #10, a vulnerable and cognitively impaired resident with a history of wandering behaviors, eloped from the facility when the receptionist unlocked the main entrance door for a vendor to exit the building. Resident #10 followed the vendor out of the main entrance. A staff member observed the Resident on the sidewalk across a 2-lane street and assisted the Resident inside the facility within 2-3 minutes of his elopement. The facility failed to continue increased supervision after 4/30/2024 at 9:45 AM. On 5/5/2024, at approximately 9:00 PM, staff discovered Resident #10 was not accounted for during a head count, after a staff member heard the main entrance door alarming and determined no one was at the main entrance. Resident #10 eloped from the facility, undetected, through the main entrance. The Resident was found at a convenience store by a staff member, approximately 0.1 miles from the facility. The Resident returned to the facility with the staff member at 9:19 PM. The facility's failure to provide adequate supervision to Resident #10 resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) for Resident #10 and placed 2 other residents identified as having the potential for elopement at risk for Immediate Jeopardy. The Administrator and Regional Director of Clinical Services were notified of the Immediate Jeopardy on 6/4/2025 at 5:35 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ began on 4/27/2024 and continued through 5/8/2024. The facility's corrective actions were completed on 5/8/2024. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for the past noncompliance, was received and validated on-site on 6/4/2025. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization .supervision .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement .and monitoring for effectiveness and modifying interventions when necessary .Supervision will be provided to help prevent accidents or elopements .The effectiveness of interventions will be evaluated, and changes will be made as needed .Active exit seeking residents will be placed under staff supervision .The patient is always accompanied by the staff member . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Alzheimer's Disease, Restlessness, and Agitation. Review of an elopement Risk Assessment for Resident #10 dated 4/16/2024, revealed the Resident was a high risk for elopement. Review of a significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Wandering behaviors were not identified on the MDS. Review of a nurse's progress note dated 4/27/2024 at 3:57 PM, revealed .At approximately 1pm, [Resident #10] went outside from the front lobby door. Staff immediately went after [Resident #10] and was able to safely escort [Resident #10] back into the building without incident. Vitals WNL [within normal limits]. Full head to toe assessment was done and resident has a small skin tear to lower right forearm. Measures 0.8cm [centimeters] X [by] 0.8cm. Area cleansed with normal saline and covered with a dry dressing. No complaints of pain voiced. Resident on 1:1 [one to one] supervision . Review of a comprehensive care plan for Resident #10 dated 4/27/2024, revealed .Resident is at risk for elopement r/t [related to] history of exit seeking behavior .4/27/24 [2024] Resident elopement from building .1:1 supervision at time of incident [elopement] and then every 15 minute checks . Review of facility documents titled, 15 Minute Increments to Verify Intense Supervision with 1:1 Acuity, for Resident #10 revealed the Resident was on every 15 minute checks from 4/27/2024 at 1:15 PM - 4/30/2024 at 9:45 AM. Review of Certified Nursing Assistant (CNA) R's written witness statement dated 4/27/2024, revealed .I was bringing my dirty dish cart to the dining area and looked out the door and saw [Resident #10] outside across the street .He was walking outside with clothes in hand across the street .Yelled out for others and notified them that [Resident #10] was outside .going after [Resident #10] during this time as well . Review of Housekeeper BB's written witness statement dated 4/27/2024, revealed .I heard [CNA R] call out Code Orange [elopement]. [Resident #10] went out the door. He crossed the road to the other side. Then I went .to grab him . Review of Receptionist S's written witness statement dated 4/27/2024, revealed .I was sitting at the front desk and let the lab tech [technician] out the door. [Resident #10] followed behind her with clothes in his hand as if he was a visitor. [Resident #10] was able to make it across the street unharmed. A nursing aid [CNA R] recognized him and went into action and secured him safely and walked him back into the building. The entire incident only lasted about 3 minutes . Review of a nurse's progress note for Resident #10 dated 5/6/2024 at 5:39 AM, revealed .[On 5/5/2025 at approximately 9:00 PM] Nurse responded to door alarm panel at the nurses [nurses ' ] station alerting the front door. Nurse did not see anyone at the door or outside the door. Nurse alerted all staff to do a head count of residents. Staff unable to locate [Resident #10] inside building or outside. [Licensed Practical Nurse-LPN T] got in vehicle and observed [Resident #10] ambulating at a fast pace down the street toward the convenience store. [Resident #10] Said 'hey how did you know I was here?' when [LPN T] called his name. [Resident #10] Stated he was headed to his apartment .Assisted into vehicle and back to the facility. No injuries noted. Mood pleasant. 1 on 1 care provided. Administrator, DON [Director of Nursing] MD [Medical Doctor], and wife notified . Review of a comprehensive care plan for Resident #10, revised 5/5/2024, revealed .5/5/24 Resident elopement from building .1:1's until discharge to another community .Door alarm company to come out and check all doors . Review of Licensed Practical Nurse (LPN) T's written witness statement dated 5/5/2024, revealed .At approximately 9 pm [9:00 PM] I heard the front door alarm sound on the panel at the nurses station. I immediately went to the front door. I did not see anyone in the front lobby or outside the front door or parking lot/road. I then went back to the floor to alert staff and do a head count. We were unable to locate [Resident #10]. While searching the building inside and outside the supervisor received a call that [Resident #10] was walking down the road. I got in my personal vehicle and drove towards [named boulevard]. I observed [Resident #10] walking at a fast pace on the side of the road towards the convenience store. I pulled over and called his name. [Resident #10] said 'hey! How did you know I was here?' I assisted [Resident #10] into my vehicle. Was in a pleasant mood without any distress noted. Said 'I was headed home to my apartment' .Reoriented to his home at [named facility] and taken to his room. 1 on 1 care provided for the remainder of the shift. [Resident #10] was assisted into my vehicle at 9:18 PM. The administrator, DON [Director of Nursing], MD [Medical Doctor], and his POA [Power of Attorney] was notified per supervisor . Review of Registered Nurse (RN) A's written witness statement dated 5/5/2024, revealed .At around [9:05 PM], I heard the door alarm sound. [Named LPN T] went to the front [and] found the door locked with no one outside or in the lobby. I and the other staff started a search .A search did not find [Resident #10] in the building. At this point I received a phone call informing me that he had been spotted outside. I went out to search for along with [Named LPN T].I continued to search for him until I received news from [Named LPN T] that she had [Resident #10] and was returning to the facility . Review of CNA Z's written witness statement dated 5/5/2024, revealed .[Resident #10] was hanging out in the front prior to eloping. In which I made him come to his room around [8:45 PM] so we could see him. [Resident #10] let us know that he opened the door by pushing it open. And was placed on 1:1 supervision for the rest of the night . Review of the medical record for Resident #10 revealed the resident remained on 1:1 supervision from the time he returned to the facility on 5/5/2025 at approximately 9:20 PM, until he was transferred to a different facility on 5/8/2024 at 12:00 PM. During an interview on 6/2/2025 at 2:00 PM, the Administrator confirmed Resident #10 had eloped on 4/27/2024 when the receptionist opened the door for a lab technician to exit the main entrance. The resident walked out of the facility behind the lab technician. The Administrator stated a staff member saw Resident #10 outside of the facility, immediately went to the resident, and brought him safely back into the facility. Resident #10 was taken to the nurse's station, where he could be monitored more closely, and was placed on every 15 minute checks. Following the incident, risk assessments were performed for every resident and the Administrator ensured warning postings were visible regarding not allowing anyone to follow visitors/vendors out of door as they leave. Resident photos in the elopement book at the receptionist desk were updated. All staff received education on the elopement policy. The Administrator stated the facility was in the process of finding placement for Resident #10 at a facility with a secure unit when the resident eloped again on 5/5/2024. The Administrator stated the Resident had been observed in the lobby at 8:45 PM and had been redirected and assisted back to his room. The Administrator stated, on 5/5/2024 at approximately 9:00 PM, a staff member heard the main entrance door alarm. A nurse (LPN T) went to the entrance, looked outside, checked the dining room and restroom, and saw no one. Other staff on duty did a head count and discovered Resident #10 was not accounted for. The Administrator stated an off-duty employee saw Resident #10 at a store .down the road . and notified the facility. LPN T drove to the store, picked up the resident, and returned the resident to the facility at 9:19 PM. Resident #10 was immediately placed on 1:1 supervision until he was discharged to a facility with a secure unit on 5/8/2024. On 5/6/2024, a contracted electric service verified the door's locking mechanism was receiving electricity and was working properly. On 5/7/2024, the facility's Regional Life Safety/Maintenance Director determined the door would close but bounced away from the doorframe not allowing the door's magnetic lock assembly to energize correctly and secure the door in the locked position. Adjustments were made to the door's self-closing device to prevent the door from bouncing away from the doorframe. Verification the locking mechanism was working correctly occurred on 5/8/2024. The facility ordered a system with wearable devices (bracelets) which tracked a resident's location and triggered alerts when they approached restricted areas or exit points on 5/8/2024. The Administrator confirmed Resident #10 eloped from the facility on 4/27/2024 and 5/5/2024. During a telephone interview on 6/2/2025 at 7:13 PM, CNA R stated Resident #10 eloped from the facility on 4/27/2024. CNA R stated .I know I recognized him [Resident #10], and it was my duty to get him back inside and keep him safe .I called a code [elopement code] and got some backup . CNA R stated [Housekeeper BB] went to Resident #10 and brought him back inside the facility. When asked if Resident #10 crossed the street, CNA R asked .what did my statement say . CNA R's statement was read verbatim .I was bringing my dirty dish cart to the dining area and looked out the door and saw the resident outside across the street . CNA R stated, .I gotta [got to] stick with whatever my statement said, cause my memory is not that vivid . During a telephone interview on 6/3/2025 at 3:45 PM, Receptionist S stated she had looked at the elopement book when her shift started [4/27/2024] to see if anyone new had been added to the book. Receptionist S stated .I had never met or seen [Resident #10] before .only saw him in the book .On this particular day, someone came in to draw blood .Had families coming in and out .It's common for families to pick up laundry on the weekend .The picture [of Resident #10] in the book didn't look like him .When I was letting out the phlebotomist [lab technician], there was a man behind her with a bag and clothes over his arm . Receptionist S stated when she opened the door for the lab technician, Resident #10 went out behind her. One of the techs (CNA R) happened to walk by and recognized the resident who had walked across the street. Receptionist S stated Resident #10 was out of the facility for 2-3 minutes. Observation of the reception desk on 6/3/2025 at 4:00 PM, revealed an elopement book was located at the desk. Resident photos who were high risk for elopement were in the notebook. During a telephone interview on 6/3/2025 at 4:10 PM, LPN T stated .I heard the alarm [front door] go off [on 5/5/2024 at approximately 9:00 PM], so I went to the front door .didn't see anybody around it or outside .had everyone do a head count .discovered [Resident #10] wasn't in there .went down the road and found [Resident #10] .he was going toward the store .he was almost there [store] .got him back in the building .We did 1:1 .had a nurse sit with him all night . LPN T stated Resident #10 was discharged to a facility with a secure unit. During an observation and interview on 6/4/2025 at 10:00 AM, with the Maintenance Director, all doors were verified as in good working condition and locking mechanisms were working appropriately. The Maintenance Director stated the doors were checked monthly to ensure the locking mechanisms were working properly. During a telephone interview on 6/4/2025 at 4:41 PM, the Medical Director stated she was aware of Resident #10 eloping from the facility on 4/27/2024 and 5/5/2024. The Medical Director stated she participated in AdHoc (urgent meetings to address specific issues which require immediate attention) Quality Assurance and Performance Improvement (QAPI) Meetings after both of Resident #10's elopements and was involved in determining next steps to prevent further resident elopements. Observations by the survey team from 6/2/2025-6/4/2025 revealed residents who were high risk for elopement were wearing bracelets which alerted staff when a resident approached an exit point. The facility's corrective actions for the removal plan were issued to the state surveyors on 6/4/2025. The corrective action plan included the following: /5/2024 - Resident #10 returned to the facility with LPN T at 9:19 PM. A complete assessment was performed for Resident #10 upon return to the facility with no injuries or change in condition noted. Resident #10 was placed on 1:1 observation. Resident #10's spouse and physician were notified. Staff ensured all facility exits were locked properly. Ad-Hoc QAPI call with leadership and Governing Board to discuss Resident #10's elopement. 100% staff educated on facility's Elopement Policy with Post-Test and was ongoing. Elopement drills were conducted on day and night shifts for both rotations on 5/6/2024, 5/8/2024, 5/20/2024, and 6/4/2024 to ensure knowledge and compliance. Resident #10's care plan was updated by MDS to include 1:1 supervision until discharge. Resident #10 was evaluated by psychiatric services on 5/6/2024. Resident #10 was seen by physician on 5/7/2024. Ad-Hoc QAPI meeting was held on 5/6/2024 with QAPI Committee and leadership team in attendance. 5/7/2024 - Verification electricity to the door locking mechanism was working properly and incident did not occur due to an electrical failure Ad-Hoc QAPI meeting was held on 5/7/2024 with Medical Director. Regional Life Safety/Maintenance Director determined the main entrance door would close, but bounced away from the doorframe, not allowing the door's magnetic lock assembly to secure the door in the locked position. Adjustments were made to the door's self-closing device. The door was tested numerous times, and the magnetic lock secured the door each time to lock securely. 5/8/2024 - Contracted company verified the locking mechanism on the main entrance door was working correctly. 5/8/2024 - Resident #10 remained on 1:1 supervision until he was discharged on 5/8/2024. Resident #10 was admitted to a facility with a secure unit as planned prior to the elopement on 5/5/2024. 5/9/2024 - Follow-up with Governing Board was held. Maintenance department conducted random door audits to ensure the doors were locking properly with no concerns noted. Monthly audits were ongoing. Results of the random door audits were reported to the QAPI committee monthly for 3 months to ensure continued working compliance of door. The Removal Plan was validated onsite by the surveyors on 6/4/2025 which included review of the facility documentation to show each step was completed and staff interviews to confirm completed and ongoing actions, elopement education, and participation in elopement drills.

Based on policy review, kitchen sanitation logs, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions when the facility failed to complete the food temperature log, dish washer temperatures, test the sanitizing solution level of the low temperature dishwasher three times a day, and when expired foods were found in the Emergency Food Supply. The facility had a census of 57 with 57 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the undated facility policy titled, Record of Food Temperatures, revealed .It is the policy of this facility to record temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Food temperatures will be checked on all items prepared in the dietary department .Measure and record the temperatures foreach food product .at all meals. Record temperature on temperature log . Review of the facility policy titled, Food Safety Requirements, dated 10/5/2020, revealed .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items .Manufacturers' instruction shall be followed for machine washing and sanitizing .For low temperature dishwashers (chemical sanitization) .The was temperature shall be 120 F [Fahrenheit] .The sanitizing solution shall be 50ppm [parts per million] hypochlorite [chlorine] on dish surface in final rinse .Chemical solutions shall be maintained at the correct concentration .at least once per shift .Results of concentration checks shall be recorded .Water temperatures shall be measured and recorded prior to each meal . Review of the facility's undated policy titled, Emergency Food Supply, revealed .It is the policy of this facility to establish procedures to ensure that food is available for residents, staff and volunteers in the case of emergency .The Dietary Manager shall maintain a 3 day supply of nonperishable foods .The emergency food is rotated/replenished every six months . 2. Review of the Food Temperature Log . dated April 2025, revealed the facility failed to log food temperatures on all three meals on the following dates: 4/9/2025, no temperatures were checked for supper. 4/11/2025, no temperatures were checked for supper. 4/12/2025, no temperatures were checked for supper. 4/13/2024, no temperatures were checked for supper. 4/18/2025, no temperatures were checked lunch. 4/22/2025, no temperatures were checked for supper. 4/23/2025, no temperatures were checked for supper. 4/24/2025, no temperatures were checked for supper. 4/25/2025, no temperatures were checked for lunch and supper. 4/28/2025, no temperatures were checked for supper. 4/29/2025, no temperatures were checked for supper. 3. Review of the DISH MACHINE LOG . sanitation log dated April 2025, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper, and initialed as being completed. Review of the sanitation log failed to reflect the completion of all the breakfast, lunch, and supper dish machine temperature checks and sanitizer checks, with staff initials on 4/11/2025, 4/25/2025, 4/28/2025, 4/29/2024, and 4/30/2025. Review of the DISH MACHINE LOG . sanitation log dated May 2025, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper, and initialed as being completed. Review of the sanitation log failed to reflect the completion of all the breakfast, lunch, and supper dish machine temperature checks and sanitizer checks, with staff initials on 5/9/2025, 5/12/2025, 5/17/2025, 5/18/2024, 5/23/2025, 5/26/2025, 5/30/2025, and 5/31/2025. Observation and interview at the Emergency Food Supply Storage Area on 6/4/2025 at 10:00 AM, revealed the following: a. 24 cans of pureed chicken with a best by date of December 22, 2022. b. 12 packets of apple juice with best by date of December 30, 2022. c. 4 bags of dry, corn cereal with best by date of February 1, 2024. d. 4 bags of dry rice cereal with best by date of February 28, 2024. e. 8 packets of Chicken Gravy with best by date of March 2024. f. 6 cans of pulled chicken with a best by date of March 23, 2024. g. 6 cans of Chili with a best by date of January 22, 2025. h. 1 bag of Nonfat dry milk 50 pounds with best by date of February 23, 2025. i. 6 cans of Carrots with best by date of April 2025. j. 6 cans of Tuna light with best by date of May 5, 2025. The Dietary Manager (DM) confirmed he had not been out to check on the emergency food in 3 months. The Registered Dietician (RD) confirmed the facility didn't have an ample supply of the 3-day emergency supply and stated, .this is sad .that means the dietician before me didn't do anything .we are in trouble . During an interview on 6/4/2025 at 3:09 PM, the RD and DM confirmed meal temperatures should be taken before each meal, and the dish wash temperature should be taken and the sanitizer checked before each wash three times a day. During an interview on 6/5/2025 at 2:39 PM, the Administrator confirmed meal temperatures should be taken before each meal, dish wash temperature should be taken before each meal with the sanitizer three times a day and the facility should not have expired foods.

Based on facility policy review, medical record review, and interview, the facility failed to assess the residents' condition, monitor for complications, implement appropriate interventions, and maintain ongoing communication with the dialysis center for 2 of 2 (Resident #19 and #42) sampled residents reviewed for dialysis. The findings include: 1. Review of the undated facility policy titled, Hemodialysis Policy, revealed .This facility will provide the necessary care, treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan .The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment .The licensed nurse will communicate to the dialysis facility .Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions .and monitoring intake and output measurements as ordered .The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The facility will communicate with dialysis facility, attending physician and/or nephrologist any significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to the dialysis treatment and document such orders .The facility will ensure that the physician's orders include the type of access for dialysis .any fluid restriction if ordered by the physician. The nurse will ensure that the dialysis access site .is checked before and after dialysis treatment and every shift for patency by auscultating for a bruit and palpating for a thrill . 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Viral Hepatitis, Alcohol induced Pancreatitis, and Blindness Right Eye. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #19 was cognitively intact and required Dialysis. Review of the Care Plan dated 6/11/2024, revealed Resident #19 was care planned for .has dialysis at [Named Dialysis facility] .on Mon [Monday] .9/22/2023 at risk for fluid imbalance r/t [related to] fluid restriction, hemodialysis, ESRD [End Stage Renal Disease] and viral hepatitis . Review of the physician orders revealed Resident #19 had an order to .12/4/2023 monitor left arm shunt site for: Bruit and thrill-if not present notify MD, two times a day related to END STAGE RENAL DISEASE .9/13/2024 Send completed dialysis communication sheet/packet with resident upon departure .3/26/2024 Remove pressure dressing per LEFT ARM AV [arteriovenous-an irregular connection between an artery and a vein] fistula dialysis access site, one time a day every Wed [Wednesday], Fri [Friday], Sun [Sunday] for post-dialysis tx [treatment]. May reapply if bleeding noted .7/19/2024 Send resident to dialysis with appropriate meal/snack if their chair time overlaps a mealtime .one time a day every Mon, Wed, Fri for Dialysis .Dialysis [is a?lifesaving treatment?for individuals with kidney failure or end-stage kidney disease. It helps remove excess fluid and waste products from the blood when the kidneys can no longer perform these functions naturally].at [Named Dialysis Facility] on Mon, Wed, Fri with 7am [7:00 AM] chair time .6/10/2024 Obtain vital signs prior to dialysis and after return from dialysis, two times a day every Mon, Wed, Fri .12/4/2023 No blood pressure or venipuncture per left arm every shift for dialysis shunt left arm . Review of the medical record revealed Resident #19 had Dialysis Communication forms dated 1/17/2025, 1/20/2025 (incomplete),1/27/2025 and an incomplete Pre/Post Dialysis Communication Report form done on 1/15/2025 and 5/9/2025. Review of the dialysis communication book revealed Resident #19 had an incomplete Pre/Post Dialysis Report dated 2/12/2025. Review of the February 2025 Medication Administration Record (MAR) revealed the facility failed to obtain 4 of 24 opportunities to monitor vitals signs prior to or after dialysis treatment. Review of the March 2025 MAR revealed the facility failed to obtain 8 of 26 opportunities to monitor vitals signs prior to or after dialysis treatment. Review of the April 2025 MAR revealed the facility failed to obtain 3 of 26 opportunities to monitor vitals signs prior to or after dialysis treatment. During an interview on 6/2/2025 at 1:58 PM, Registered Nurse (RN) N was asked where the dialysis communication book was, and RN N was unable to locate the book. The communication sheets for the past 90 days were requested, and the facility was unable to provide any additional sheets. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including End Stage Renal Disease, Diabetes Mellitus, Renal Dialysis, and Hypertension. Review of the Nutritional Dietary/Notes dated 2/3/2025, revealed the Registered Dietician (RD) recommended a fluid restriction of 1200 milliliters (ml) a day. The facility was unable to provide documentation regarding the recommended fluid restriction for Resident #42. Review of the physician's orders dated 3/1/2025, revealed Resident #42 had an order for dialysis on Monday, Wednesday, and Friday. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #42 was cognitively intact. Resident #42 required set up for eating, substantial assistance with bed mobility and transfers, and was coded for a diabetic diet and dialysis. The facility was unable to provide documentation of the Permcath [a device used for hemodialysis] access site monitoring for March 2025, April 2025, and May 2025. Review of the Care Plan for Resident #42 dated 6/1/2025, revealed .Access site located on right upper chest, observe access site for complications such as s/s [sign and symptoms] of infection, no bruit thrill, s/s of bleeding and report immediately . Resident is at risk for fluid restriction per md order . Fluids divided up between disciplines during day by recommendation of RD . Obtain report from dialysis clinic such as paperwork . The facility was unable to provide documentation of verbal or written communication for Resident #42 with dialysis clinic. During a telephone interview on 6/3/2025 at 10:27 AM, the Clinical Nurse Manager for Dialysis Clinic EE was asked if she received a pre-weight on Resident #42 or any communication when Resident #42 came to her dialysis appointments. The Clinical Nurse Manager stated, No .there has never been any pre-weights sent with [named Resident #42] and [I] have not seen a facility dialysis communication sheet. During an interview on 6/4/2025 at 1:54 PM, Licensed Practical Nurse (LPN) M confirmed that Resident #42 was not on a fluid restriction. During an interview on 6/5/2025 at 12:03 PM, the RD was asked do you know if Resident #42's fluid restriction recommendation was implemented. The RD stated, No, a lot of my recommendations don't get implemented. The RD was asked if it was her responsibility to follow up to see why a recommendation was not implemented. The RD stated, Yes, but I don't have time to follow up on all my recommendations. When it is not done, I assume the nurses know more than me. The RD was asked if she had talked with the RD at the dialysis clinic. The RD stated, I have not. The RD was asked should you have communicated with the RD at the dialysis clinic. The RD stated, Of course I should have communicated with the RD. The RD was asked if there should be pre and post dialysis weights done at the facility. The RD asked, .is it being done. During an interview on 6/5/2025 at 2:13 PM, the Director of Nursing (DON) was asked if a fluid restriction was recommended for a dialysis resident, should it be implemented. The DON stated, Yes, it should. The DON was asked what the process was for implementing the RD recommendations. The DON stated, They [RD recommendations] are emailed to me, and I passed on to the Medical Director (MD), [the] MD would approve the recommendation. The DON was asked if the nurses should assess the dialysis site after dialysis and document its findings for Resident #42. The DON stated, Yes, and it should be a part of their assessment. The DON was asked if the facility policy was followed. The DON stated, No, it was not. During an interview on 6/5/2025 at 3:27 PM, the DON was asked does the nurse provide a pre-weight to the dialysis clinic. The DON stated, Currently we do not send any weight documentation to the dialysis clinic. The DON was asked should the nurse obtain and communicate Resident #42's pre-weight to the dialysis clinic. The DON stated, Yes, we should have a dry weight on the resident.

Based on review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interview, the facility failed to accurately assess the use of antipsychotic medication for 1 of 6 (Residents #31) sampled residents reviewed. The findings include: 1.Review of the RAI Manual dated 10/2024, revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .SECTION N: MEDICATIONS .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications .1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day lookback period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home .Code all high-risk drug class medications according to their pharmacological classification, not how they are being used .N0415A1 .Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) .N0415A2 .Antipsychotic: Check if there is an indication noted for all antipsychotic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses including Epilepsy, Presence of Cerebrospinal Fluid Drainage Device, Hungry Bone Syndrome, Dementia, Schizophrenia, Anxiety Disorder, Traumatic Brain Injury, Unspecified Intellectual Disabilities, Obstructive Hydrocephalus, and History of Falls. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS) assessment was not conducted due to Resident #31 was rarely/never understood. Further review revealed Resident #31 had not received antipsychotic medications within the last 7 days prior to the MDS completion date of 4/14/2025. Further review revealed Resident #31 had not received antipsychotic medications since admission/entry or readmission. Review of the Care Plan Report for Resident #31 revealed, .Focus .Receives .antipsychotic .medication r/t [related to] .psychosis, schizophrenia . initiated 1/25/2024, with revision on 1/10/2025. Review of an Internal Medicine Progress Note for Resident #31 dated 6/2/2025, revealed .Medications: Seroquel [medication to treat Schizophrenia] 100 mg [milligrams], Give 150 mg by mouth two times a day . Review of the Order Recap Report for Resident #31 dated 6/3/2025, revealed an active order with a start date of 12/30/2024, for .Seroquel Oral Tablet 100 mg (Quetiapine Fumarate) Give 150 mg by mouth two times a day . Review of the Medication Administration Record (MAR) revealed Resident #31 received, .Seroquel Oral Tablet 100 mg .Give 150 mg by mouth two times a day . at 8:00 AM and 8:00 PM during April 2025. During an interview on 6/4/2025, at 10:55 AM, the Regional Director of Clinical Services confirmed that Resident #31 received antipsychotic medications during the 7-day period prior to the MDS Assessment Reference Date of 4/14/2025 and the antipsychotic medications were not accurately coded on the MDS.

Based on facility policy review, record review, and interview, the facility failed to follow physician's orders and administer medications according to professional standards, as well as facility policy, for 1 of 6 (Resident #15) residents reviewed. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed, .Medications are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .10. Review MAR [Medication Administration Record] to identify medication to be administered .17. Sign MAR after administration .18. If medication is a controlled substance, sign narcotic book .20. Correct any discrepancies and report to nurse manager . Review of the undated facility policy titled, Controlled Substance Accountability, revealed, .It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances .1. General Protocols .h. The Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration .j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: ii. Mediations removed from either the automated dispensing system or medication cart/cabinet have a documented physician order . 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses including Parkinson's Disease, Sepsis, Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Depression, and Anxiety. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #15 was cognitively intact. Further review revealed Resident #15 received antianxiety, antidepressant, and opioid medications. Review of the physician's orders for Resident #15 revealed an order for .Clonazepam Oral Tablet 0.5 MG [milligram] Give 0.25 mg via G-Tube at bedtime for schizophrenia AND Give 0.25 mg via [by way of] G-Tube [A feeding tube inserted into the stomach to deliver nutrition and medication] every 12 hours as needed for anxiety ., with a start date of 7/29/2024 and was discontinued on 8/14/2024. Continued review revealed an order for, .clonazepam oral 0.5 mg (milligram) (Clonazepam) Give 0.25.mg via PEG [percutaneous endoscopic gastrostomy] Tube [A medical device that delivers nutrition directly to the stomach or small intestine through a flexible tube] two times a day for Anxiety . with a start date 8/16/2024. Review of the Controlled Drug Receipt Record/Disposition Form for Resident #15, received 7/29/2024, revealed a physician's order, printed at the top of the form, for .Clonazepam 0.5 mg Tabs (tablets) .Take 1/2 tablet via tube every 12 hours as needed; Give 1 tablet via tube at bedtime .(half tabs) . Continued review of the Controlled Drug Receipt Record/Disposition Forms received 7/29/2024 and 8/17/2024, revealed Clonazepam 0.5 mg (1/2 tablet x 2) were signed off as given at 9:00 PM on 9/2/2024, 9/5/2024, 9/6/2024, 9/7/2024, 9/8/2024, and 9/9/2024. Review of the Medication Administration Record (MAR), dated 9/1/2024-9/30/2024, revealed Resident #15 received Clonazepam 0.25 mg via PEG Tube two times daily at 9 AM and PM. During an interview on 6/4/2024 at 2:30 PM, the Regional Director of Clinical Services confirmed that the physician's order for Clonazepam located at the top of the Controlled Drug Receipt Record/Disposition Form received 7/29/2024 for Resident #15 had been discontinued and that the the most recent physician's order for Clonazepam 0.5 mg tablets-Take 1/2 tablet via tube every 12 hours started on 8/16/2024. She further confirmed that on the Controlled Drug Receipt Record/Disposition Forms, Clonazepam 0.5 mg (1/2 tablet) x 2 were signed out as given, at 9:00 PM on 9/2/2024, 9/5/2024, 9/6/2024, 9/7/2024, 9/8/2024, and 9/9/2024, and only 1 (1/2 tablet) should have been given per the physician's order that had started 8/16/2024.

Based on facility policy review, medical record review, and interview, the facility failed to ensure medications were stored and administered safely when medications were left unattended in resident's room during medication administration for 1 of 6 (Resident #5) residents reviewed. The findings include: 1. Review of the undated facility policy titled, Medication Storage, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .1. General Guidelines .c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Review of the facility's undated policy titled, Medication Administration, revealed, .Medications are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .15. Observe resident consumption of medication . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with readmission on [DATE], with diagnoses including Unspecified Injury at C7 Level of Cervical Spinal Cord, Quadriplegia, Post Traumatic Stress Disorder, Cognitive Communication Deficit, Depression, and Anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #5 was cognitively intact. Further review revealed Resident #5 received antianxiety, antidepressant, anticonvulsant, and opioid medications. Review of the physician orders for Resident #5 dated 5/2/2024, revealed, .Oxycodone HCL [Hydrochloride] [A type of semi-synthetic opioid agonist used to relieve moderate to severe pain] oral tablet 15 mg [milligrams] Give 30 mg by mouth every 4 hours as needed for pain scale 9-10 . Review of the Previous Assistant Director of Nursing (ADON) Q's signed statement dated 9/10/2024, revealed .On this date resident (Resident #5) reported to me that a night nurse attempted to give her the wrong pain medication .Resident states that (RN [Registered Nurse]) A then exited the room leaving her medications on her overbed table .Resident left the medication on her table for me to view upon entrance to the building . Review of a Detail of Complaint, statement for Resident #5 dated 9/11/2024, revealed .On the date of 9/10/2024 [Previous ADON Q] was called to the room of resident [Resident #5]. Upon entering resident's room, the resident stated that she had not received the correct Pain medication this morning. Resident stated the night shift nurse came into my room at 0600 [6:00 AM] this morning to give me my medication. She was trying to hurry me up to take my medications. I told the nurse that I must wake up before I can take medications. Then the nurse set the medication cup on the bedside table and left the room. When I looked in the cup, I noticed I had two pills that I wasn't supposed to take. I asked for the nurse to return to my room on 3 separate occasions and she never returned. I left the medication cup on the bedside table for the ADON to see . During a phone interview on 6/4/2025 at 2:19 PM, Previous ADON Q stated that Resident #5 had reported to her on 9/10/2024 that RN A had left her 6:00 AM medications in her room sitting on top of her bedside table for her to take at a later time. Previous ADON Q confirmed that she observed medications in a medication cup sitting on top of Resident #5's bedside table. Previous ADON Q stated, She had kept the pills for me to look at. Previous ADON Q stated, They (nurses) are not supposed to leave meds (medications) with patients. They are supposed to watch them take their meds, not leave them sitting in a cup. During an interview on 6/4/2024 at 3:03 PM, the Director of Nursing (DON) stated that when administering medications to residents, the nurse should Make sure they [residents] take their meds. They should not be left at the bedside for any reason.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #258) resident on Transmission Based Precautions. The findings included: 1. Review of the facility policy titled Infection Prevention and Control Program, dated 1/24/2025, revealed .The facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .All staff are responsible for following all policies and procedures related to the program .All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE .Isolation Protocol (Transmission-Based Precautions) . 2. Review of the medical record revealed Resident #258 was admitted to this facility on 5/29/2025, with diagnoses including Cerebral Infarction, Diabetes, and Clostridium Difficile. Review of the medical record revealed Resident #258 was a new admission and the Minimum Data Set was not yet due or completed. Review of the undated Care Plan revealed Resident #258 .has C [clostridium] Difficile . Review of the Order Review History Report dated 5/4/2025-6/4/2025, revealed Resident #258 had an order for Contact Isolation (related to r/t) Clostridium Difficile (C-Diff) every shift for 10-Days. Review of the May 2025 Medication Administration Record revealed .in single room isolation alone every shift. Resident receives all services in room during isolation period . Observation in Resident #258's room on 6/3/2025 at 8:06 AM, revealed Certified Nurse Assistant (CNA) Y entered the room and failed to don a gown and gloves. Observation in Resident #258's room on 6/3/2025 at 8:16 AM, revealed CNA Y donned a gown and no gloves, brought in additional food items, and set them up on the overbed table. Observation in Resident #258's room on 6/03/2025 at 08:38 AM, revealed CNA X picked up food tray from the Contact Isolation room without PPE, removed the food and placed the food tray on cart in the hallway. Once the trays on the hall were collected the cart was pushed into the Dining Room and left unsupervised. There was no distinction made between the isolation tray and non-isolation trays. During an interview on 6/5/2025 at 3:22 PM, Licensed Practical Nurse (LPN), Wound Care Certified (WCC))/Infection Preventionist (IP) was asked if there were any provisions in place for trays in the Contact Isolation rooms. The WCC/IP stated they handle those trays just like the other trays because the cleaning process will kill those organisms. The WCC/IP was asked what should be worn by staff when they enter a Contact Isolation room. He stated a gown and gloves should be worn, and no one should enter the room without a gown and gloves. During an interview on 6/5/2025 at 3:30 PM, the Director of Nursing (DON)was asked what PPE should be worn by staff when they enter Contact Isolation rooms. The DON stated, They should wear gown and gloves. When asked how they should handle the food trays in Contact Isolation rooms, the DON stated, This is the first facility that I have been to that doesn't use disposable trays. The DON confirmed the best practice would be for the staff to use disposable trays going forward with residents on Contact Isolation.

Based on policy review, Licensed Practical Nurse (LPN) Job Description review, medical record review, and interview, the facility failed to ensure Licensed Staff notified the resident's attending Physician and Responsible Party when there was a significant change in the resident's condition for 1 of 6 sampled residents (Resident #5) reviewed for change in condition. Resident #5 had a significant change in status and was in respiratory distress for approximately 5 hours and 30 minutes after oxygen therapy was initiated before the Physician was notified, which placed Resident #5 in Immediate Jeopardy. Once the Physician was notified, Resident #5 was transferred to a local hospital, admitted to the Intensive Care Unit (ICU), and was diagnosed with [CONDITION(S)], Pneumonia, and Acute Respiratory Failure. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/26/2021 at 4:34 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-580. The Immediate Jeopardy was effective 3/10/2021 through 3/28/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/28/2021 at 3:53 PM, and was validated onsite by the surveyors on 3/28/2021-3/29/2021 through review of the assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) minutes, observations, and staff interviews. The findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 10/2017, showed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Our facility shall promptly notify the resident, his or her attending physician, and representative .of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .There is a significant change in the resident's physical, mental, or psychosocial status . Review of the LPN Job Description, revised 6/2006, showed, .Provide direct nursing care to residents .in accordance with current Federal, State, and Local standards .Notify the resident's attending physician and responsible party when there is a change in the resident's condition . Review of the closed medical record, showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #5 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 required extensive assistance from 2 staff members for all activities of daily living (ADLs) and supervision for meals. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen at ([left blank]) liters [L] per nasal cannula as needed for oxygen saturation less than ([left blank]) .Titrate O2 [Oxygen] to keep O2 Saturation above or equal to 92% [percent], notify Provider if more than 3 L/min [3 liters per minute] is required . Review of a Progress Note dated 3/10/2021 at 5:08 AM, documented by LPN #1, showed, .at approx. [approximately] 230a [2:30 AM] pt [patient] noted to respond less than normal for pt. pt responding to questions with simple yes and no answers but unable to vocalize more. o2 sats [O2 Saturation levels] decreased to range of 78-82% on room air .hr [heart rate] and resp [respirations] elevated .pt put on o2 at 4 lpm [liters per minute] with minimal effectiveness noted. o2 sat 82-85% hr and resp cont [continue] to be elevated [at] 110-120 bpm [beats per minute] and 22-24 resp .still cannot verbalize more than yes or no answers. pt lying in bed on left side .will cont to monitor pt status this shift . Review of a Progress Note dated 3/10/2021 at 8:15 AM, documented by Registered Nurse (RN) #1, showed, .Resident very lethargic this morning with a [an] oxygen level of 80% on 5L [liters of oxygen]. Heart rate of 128 .Phoned POA [Power of Attorney] but did not get an answer. Phoned seconded [secondary] emergency contact and notified them whom stated they would try to get in touch with POA. Phoned MD [Medical Doctor] who gave the order to send resident out to the hospital. POA called back as EMTs [Emergency Medical Technicians] were arriving .Informed POA .that he will most likely be sent to [Named Hospital] due to it being closer and [due] to residents [resident's] condition. POA stated understanding. Resident left at approx. 8AM [8:00 AM] via stretcher . Review of the medical record, showed there was no documentation the Physician or the Nurse Practitioner were notified on 3/10/2021 of Resident #5's change in condition or that oxygen was applied at 2:30 AM on 3/10/2021. The Physician was not notified until approximately 8:00 AM on 3/10/2021. During a telephone interview on 3/24/2021 at 1:10 PM, the Nurse Practitioner (NP) confirmed she had not been notified during the night of Resident #5's acute changes and stated, .if I had been notified of the resident's change, I would have done something . During an interview on 3/24/2021 at 3:48 PM, the DON confirmed the Physician should be notified of changes in residents' condition, decreased oxygen saturation, elevated heart rate, elevated respirations, and stated, I talked with [Named LPN #1] couple of days after about the note just because it was confusing the way the note read .I didn't ask him if he notified the doctor when I talked to him . During a telephone interview on 3/24/2021 at 6:30 PM, LPN #1 stated, .he [Resident #5] was lethargic .he started going down .his heart rate and respirations increased .I put oxygen on him .I monitored him by checking his vitals [blood pressure, pulse, oxygen saturation, and respirations] and asked him how he was doing about every 30 minutes until the end of my shift . LPN #1 was asked if he had documented the vital signs. He stated, .I didn't document the vitals .he didn't continue to decline so I wasn't that concerned . During a telephone interview on 3/25/2021 at 3:09 PM, LPN #2 confirmed she worked the night Resident #5's condition declined. She stated, .The CNA [Certified Nursing Assistant #1] reported a difference in [Named Resident #5]. I got called to look at him, I went in the room, he was different . LPN #2 was asked if she assessed the resident. She stated, .no I didn't because [Named LPN #1] was assigned to him that night .I just know there was a noticeable decline . During a telephone interview on 3/25/2021 at 3:31 PM, Resident #5's Physician was asked if he was notified that Resident #5's oxygen saturation had decreased during the night on 3/10/2021. The Physician stated, No, if I had been notified, I would have sent him out immediately. During an interview on 3/25/2021 at 4:18 PM, Firefighter #1 stated, .best I remember when we got there EMS [Emergency Medical Services] was right behind us .[we had] told them to give us a call if they need us .[EMS] waved at us to come help .I jumped in to help .I rode in the back [of the ambulance] .he [Resident #5] was in respiratory distress .pretty acute .working at breathing, had a non-rebreather [special oxygen mask that delivers higher concentrations of oxygen] on plus a nasal cannula .he never said anything, would just stare off .labored breathing .was pale and labored breathing .pulse 130 .respirations 24 . During an interview on 3/26/2021 at 10:33 AM, CNA #1 stated she gave Resident #5 a shower sometime after her shift began at 11:00 PM, and he seemed normal. She confirmed that on her next round, around 2:00 AM, he was not responding to her, and she notified LPN #1. She confirmed LPN #1 came in Resident #5's room and took his vital signs at that time. During an interview on 3/26/2021 at 10:38 AM, LPN #1 confirmed he had obtained vital signs on Resident #5 after CNA #1 had notified him of Resident #5's change in condition. He confirmed he placed Resident #5 on 4 liters of oxygen using a binasal cannula. He confirmed Resident #5's O2 sats were 78-82% on room air, and 82-85% after O2 was applied. LPN #1 was asked if Resident #5's O2 sats stayed in this range the rest of the shift. LPN #1 stated, They did. LPN #1 was asked if the Physician or Nurse Practitioner were notified of this change in condition. LPN #1 stated, Nobody. LPN #1 was asked if the Physician or Nurse Practitioner should have been notified of Resident #5's change in condition. LPN #1 stated, I didn't call the doctor .he seemed stable. LPN #1 confirmed he knew how to use the on-call process for notifying the Physician at night, but stated he did not know who the on-call doctor was for that night. During an interview on 3/27/2021 at 10:49 AM, the DON stated, .The root cause I identified is not notifying the physician .a lot could have been handled in that situation if a Physician had been notified .the follow up assessments should have been documented .put the ball in their court [the doctor] . Refer to F-600 and F-684. The surveyors verified the Removal Plan by: 1. On 3/1/2021-3/27/2021, chart audits were completed for all residents to ensure all acute changes were documented with notifications to the Physician, family, and DON/designee. Findings were reported in a QAPI and Ad Hoc (as needed) QAPI meeting on 3/27/2021 to include the facility leadership team, the Governing Body, and the Medical Director. The surveyors reviewed the chart audits, confirmed the QAPI and the Ad Hoc meeting held on 3/27/2021, and interviewed the Administrator and the DON. 2. On 3/27/2021, LPN #1 and LPN #2 were suspended, and education was given on neglect, notification, and Quality of Care. LPN #1 and LPN #2 were placed on action plans with monitoring of charting and acute changes for 30 days. The surveyors interviewed LPN #1 and reviewed the in-services and disciplinary action for LPN #1 and LPN #2. 3. Beginning on 3/26/2021, education was provided to staff regarding oxygen application, abnormal and concerning oxygen saturation levels that would be concerning and when to report to the Physician. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed staff on all shifts. 4. On 3/12/2021-3/29/2021, all Licensed Nurses were educated on notifying the Physician, family, and the DON/designee of changes in the resident's condition. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed Licensed Nurses on all shifts. 5. All new hires and contract staff will be provided the additional education on physician notification of a resident's change in condition going forward. The surveyors reviewed the new hire packet and interviewed the Administrator. 6. The DON or designee will perform chart audits and health assessments daily for 4 weeks, 5 days for 4 weeks, then 3 days for 4 weeks. The results were reported in an Ad Hoc meeting on 3/27/2021 and will be reviewed in monthly QAPI meetings. The surveyors reviewed the audit forms and interviewed the Administrator and the DON.

Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, Licensed Practical Nurse (LPN) job description review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to neglect of residents, failed to develop plans of action and interventions for resident neglect, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to neglect and physician notification. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure residents were free from neglect and did not have a delay in urgent treatment resulted in Immediate Jeopardy when Resident #5 had a decline in alertness, a decrease in oxygen saturation (O2 sat) (amount of oxygen measured in the blood) level of 78-82 percent (%) (Normal range is 95-100%), and developed increased pulse and respiratory rate. Resident #5 was transferred to a local emergency room where it was determined he had developed [CONDITION(S)] (a life threatening condition that arises when the body's response to infection causes injury to the tissues and organs), Pneumonia, and Acute Respiratory Failure. 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 Chief Operating Officer, Regional Director of Operations, Regional Director of Clinical Services, Administrator, and DON were notified of the Immediate Jeopardy for F-867 on 3/27/2021 at 1:05 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-580, F-600, F-684, and F-867. The facility was cited at F-600 and F-684 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 3/10/2021 through 3/28/2021. The facility was previously cited F-600 at a scope and severity of J on a complaint survey completed on 4/24/2019. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/28/2021 at 3:53 PM, and was validated onsite by the surveyors on 3/28/2021-3/29/2021 by review of the assessments, auditing tools, in-service training records, policies, QAPI minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, .Quality Assurance and Performance Improvement (QAPI), showed, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .The QAA Committee shall be interdisciplinary and .Consist at a minimum of .The Director of Nursing Services .The Medical Director or his/her designee .At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role and .The Infection Preventionist .Meet at least quarterly and as needed .Develop and implement appropriate plans of action to correct identified quality deficiencies .Key components of this process include .Tracking and measuring performance .Establishing goals and thresholds for performance improvements .identifying and prioritizing quality deficiencies .Systematically analyzing underlying causes of systemic quality deficiencies .Developing and implementing corrective action or performance improvement activities .Monitoring and evaluating the effectiveness of corrective action/performance improvement .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program .may include .The written QAPI plan .Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events .Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities .The plan and supporting documentation will be presented to the State Survey Agency .upon request . Review of the facility's Nursing Home Administrator job description, revised 6/2006, showed, .To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .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 .Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies .Maintain a working knowledge of and confirm compliance with all governmental regulations .Consult with department managers concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Protect residents from neglect, mistreatment, and abuse .Comply with the Residents' Rights and Facility Policies and Procedures . Review of the facility's DON job description, revised 6/2006, showed, .To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .In the absence of the Administrator and Assistant Administrator .assume responsibility of the facility .Monitor the Level of Care Reports, Dietary Consultant Reports, and Pharmacy Consultant Reports and take appropriate actions .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .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 department .Meet monthly with nursing staff regarding Chart Audit and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with Corporate policies and State and Federal regulations .Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the residents request .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided .Review Quality Indicator reports and submit to Vice President of Clinical Services on a monthly basis . Review of the Licensed Practical Nurse (LPN) Job Description, revised 6/2006, showed, .Provide direct nursing care to residents .in accordance with current Federal, State, and Local standards .to maintain the highest degree of quality care at all times .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .Chart nurses' notes in an informative and descriptive manner that reflects the care provided .Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practice .Notify the resident's attending physician and responsible party when there is a change in the resident's condition .Monitor seriously ill residents .Protect residents from neglect . Review of the facility's QAPI documentation showed the last QAPI meeting was held February 26, 2021. Review of the QAPI notes for the February meeting showed neglect was not discussed. During an interview on 3/24/2021 at 3:48 PM, the DON confirmed she did not get a statement from LPN #1 regarding the incident with Resident #5's delayed treatment or failure to notify the Resident's Physician or Responsible Party. During an interview on 3/26/2021, beginning at 10:35 AM, the DON confirmed the 24 hour report from 3/10/2021 had LPN #1's progress note on it and no concerns were identified during that meeting. The DON was asked if she had discussed the documentation of the resident's change in status during the night. The DON stated, .I don't think it was .more of a review type thing that morning .it helps me plan my day .what I need to look at .training .I reviewed the progress note I think it was the next day .the nurses' note was confusing so I reached out to the nurse for clarification . During further interview with the Administrator and DON, they stated, .the clinical meeting/case management meeting we have every Friday could easily be a QA meeting .all of the required members are present during that meeting . The facility did not provide any documentation of the clinical /case management meeting from 3/12/2021-3/26/2021. During a telephone interview on 3/26/2021 at 3:35 PM, the Medical Director confirmed he attends case management meetings every Friday and that he vaguely remembers something mentioned about Resident #5. The Medical Director was asked if he was notified that Resident #5 experienced a significant change in his condition. The Medical Director stated, .doesn't stand out as being that dramatic but obviously it is . During an interview on 3/27/2021 at 10:49 AM, the Administrator stated, .I wasn't focused .if I had I would have made sure we looked in to it [Resident #5's change in status] further .I can see the neglect now .we would all be in a better position right now .the breakdown is where the physician didn't get contacted .the root cause . During an interview on 3/29/2021 at 11:11 AM, the DON was asked if their QAPI program was effective in identifying neglect. The DON stated, No. During an interview on 3/29/2021 at 5:21 PM, the DON was asked what information system the facility has in place to identify quality concerns so that they can implement a systematic approach to address those concerns. The DON stated, .[Named electronic documentation program] morning clinical review of the last 24 hours, and we get with that staff member that it goes to . The DON was then asked how quality concerns get to the QAPI committee to be addressed. The DON replied, .if identified they are brought to the committee with falls, weight loss, wounds, and pain management if identified . The DON was then asked what time commitment the staff involved have in performing QAPI. The DON stated, .Leadership needs to be actively engaged in overseeing the program. This should include all levels of staff in the facility . Refer to F-580, F-600, and F-684. The surveyors verified the Removal Plan by: 1. Beginning on 3/1/2021, chart audits were completed for all residents to ensure all acute changes were documented with notifications to the Physician, family, and DON/designee. These audits were completed 3/27/2021. The results were reported in an Ad Hoc (as needed) QAPI meeting on 3/27/2021 with the facility leadership team, the Medical Director, and the Governing Body. The results were also reviewed during the monthly QAPI meeting. The surveyors verified the documentation of the chart audits, confirmed the Ad hoc QAPI meeting, and interviewed the Administrator and DON. 2. By 3/28/2021, the QAPI team will be educated on the QAPI program to ensure understanding of the functions of the program. The surveyors reviewed the sign in sheet, the education provided, and interviewed members of the QAPI team. 3. By 3/29/2021, all employees will be educated on the QA removal process. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed staff on all shifts. 4. The DON or designee will complete chart audits/health document assessments during the morning clinical meeting with 100% resident audit 7 days a week for 4 weeks, 5 days for 4 weeks, and then 3 days for 4 weeks, or until 100% substantial compliance, with immediate corrective actions as needed. The surveyors reviewed the audit forms and interviewed the DON. 5. The results of the audits and corrective actions will be reviewed for effectiveness for poor Quality of Care, failure to provide notification, and neglect in the monthly QAPI meeting for the next 3 months. Ad Hoc QAPI meetings will also be conducted as needed. The surveyors reviewed the audit forms and interviewed the Administrator and the DON. 6. The QAPI members revised the Monday through Friday daily QA meeting format. The 24-hour report and progress notes will be reviewed at each meeting. The surveyors interviewed the Administrator and the DON. 7. The QAPI meetings will be led by the Administrator, with the Medical Director in attendance. The Regional Director of Operations or the Regional Director of Clinical Services will attend and provide oversight and direction, to ensure the facility uses its resources to attain or maintain the highest practicable mental, physical, and psychosocial well-being of each resident. Findings will be reported to the QAPI team and will be reviewed by the Regional Director of Operations or the Regional Director of Clinical Services for 3 months or until compliance. The surveyors interviewed the DON and the Administrator. The facility's noncompliance at F-867 continues at a scope and severity of D for the monitoring of the effectiveness of the correction actions. The facility is required to submit a Plan of Correction.

Based on policy review, Licensed Practical Nurse (LPN) job description review, medical record review, and interview, the facility failed to ensure a resident was free from neglect when Licensed Staff neglected to provide adequate treatment when a resident had a significant decline in his condition for 1 of 6 sampled residents (Resident #5) reviewed for neglect and change in condition, which resulted in Immediate Jeopardy for Resident #5. Licensed Staff neglected to monitor Resident #5's declining condition and neglected to notify the Physician of the significant change in Resident #5's condition. The staff's neglect resulted in Immediate Jeopardy when Resident #5's oxygen saturation (O2 sat) (amount of oxygen measured in the blood) level was 78-82 percent (%) on room air and was 80% on 4 liters (L) of O2. The Physician was notified approximately 5 hours and 30 minutes after Resident #5 suffered respiratory distress. Resident #5 was ultimately transferred to a local hospital where he was admitted to the Intensive Care Unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/26/2021 at 4:34 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 3/10/2021 through 3/28/2021. An Acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/28/2021 at 3:53 PM, and was validated onsite by the surveyors on 3/28/2021-3/29/2021 through interviews, review of the Ad Hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, review of in-service training records and audits. The facility was previously cited F-600 at a scope and severity of J on a complaint survey completed on 4/24/2019. The findings include: Review of the facility's undated policy titled, Abuse Prevention Program, showed, .to prevent resident abuse, neglect .each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Neglect/Mistreatment: means the failure to provide .adequate medical treatment .that is necessary to avoid physical harm, mental anguish .of a resident . Review of the LPN Job Description, revised 6/2006, showed, .Provide direct nursing care to residents .in accordance with current Federal, State, and Local standards .to maintain the highest degree of quality care at all times .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .Chart nurses' notes in an informative and descriptive manner that reflects the care provided .Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practice .Notify the resident's attending physician and responsible party when there is a change in the resident's condition .Monitor seriously ill residents .Protect residents from neglect . Review of the facility's policy titled, Resident Rights, revised 3/2018, showed, .must immediately .consult with the Resident's physician and the Resident's legal representative or an interested family member when there .is a significant change in the Resident's physical, mental or psychosocial status (a deterioration in health in either life-threatening conditions or clinical complications) . Review of the closed medical record, showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #5 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 required extensive assistance from 2 staff for all activities of daily living (ADLs) and supervision for meals. Review of the Comprehensive Care Plan dated 2/8/2021, showed Resident #1 was care planned for oxygen therapy as needed related to Shortness of Breath. The goal of the Care Plan was for Resident #5 to have no signs or symptoms of poor oxygen absorption. The interventions included giving medications as ordered by the physician, monitoring and documenting side effects, and if the interventions were effective. Review of a Progress Note dated 3/10/2021 at 5:08 AM, documented by LPN #1, showed at approximately 2:30 AM Resident #5 was noted to respond less than normal, only responding to questions with simple yes and no answers, and unable to vocalize more. Resident #5's O2 sats decreased to a range of 78-82% on room air, his heart rate and respirations were elevated. LPN #1 placed O2 at 4 L per minute on Resident #5. Resident #5's O2 sats were 82-85%, heart rate continued to be elevated at 110-120 beats per minute (bpm), and his respirations were 22-24 breaths per minute. Resident #5 was still unable to verbalize more than yes or no answers. Review of the medical record, showed there was no other documentation of vital signs obtained or continued monitoring of Resident #5 by facility staff after 2:30 AM. Review of a Progress Note dated 3/10/2021 at 8:15 AM, documented by Registered Nurse (RN) #1, showed that Resident #5 was very lethargic with an O2 sat of 80% on 5 L of oxygen per minute. His heart rate was 128 bpm. RN #1 attempted to contact the Power of Attorney (POA) and was unable to reach them by telephone. Resident #5's second contact was notified by telephone. RN #1 telephoned the Physician to report Resident #5's condition and was given an order to send Resident #5 to the emergency room . Resident #5's POA returned the call and was informed that Resident #5 would be sent to (Named Hospital), due to the (Named Hospital) being closer and the resident's declining condition. The POA stated understanding. Resident #5 left the facility at approximately 8:00 AM on a stretcher via Emergency Medical Services (EMS). Review of the hospital Emergency Visit Note dated 3/10/2021 at 10:11 AM, showed, .time seen 8:26 [AM] .altered mental status and respiratory failure .patient found by staff last night to have decreased alertness and requiring oxygen. O2 sat this morning was in the mid 80s and they called EMS [Emergency Medical Services]. Patient was placed on oxygen by nonrebreather [special oxygen mask that delivers higher concentrations of oxygen] and oxygen saturation and alertness did improve. Patient is currently on 15 L by nonrebreather and oxygen saturations are 96% .physical exam awake and able to sit up but unable to answer any questions or follow any instructions .moderate respiratory distress .altered mental status .patient is septic .infected urine and possible pneumonia on chest xray. Oxygen sats maintained on High Flow NC [Nasal Cannula] at 30L .admitted to ICU .Clinical Impression: Pneumonia, Respiratory Failure, Acute UTI [Urinary Tract Infection], Altered Mental Status, [CONDITION(S)], Condition: Critical . Review of the hospital History and Physical dated 3/10/2021 at 12:45 PM, showed Resident #5 was diagnosed with Acute Septic Shock, Pneumonia, Acute Respiratory Failure, and Acute UTI. The chief complaint was [CONDITION(S)] (an absence of enough oxygen in the tissues to sustain bodily functions). During a telephone interview on 3/19/2021 at 9:54 AM, LPN #1 confirmed that Resident #5 was not his normal self, he could only answer yes and no questions, but was unable to vocalize more. His oxygen saturation was between 78-82% and he had put oxygen on Resident #5 at 4 L per minute. LPN #1 stated, .he [Resident #5] didn't get any worse . LPN #1 was asked if he notified the Physician of the resident's change in condition. LPN #1 stated, .I probably should have called someone . During a telephone interview on 3/24/2021 at 1:10 PM, the Nurse Practitioner (NP) stated, .if I had been notified of the resident's change, I would have done something .I don't recall being notified . During a telephone interview on 3/24/2021 at 6:30 PM, LPN #1 stated, .he [Resident #5] was lethargic .he started going down .his heart rate and respirations increased .I put oxygen on him .I monitored him by checking his vitals [blood pressure, pulse, oxygen saturation and respiration] and asked him how he was doing about every 30 minutes until the end of my shift . LPN #1 was asked if he had documented the vital signs. LPN #1 stated, .I didn't document the vitals .he didn't continue to decline so I wasn't that concerned . LPN #1 confirmed that LPN #2 had looked at the resident because he didn't look good. During a telephone interview on 3/25/2021 at 3:09 PM, LPN #2 stated, .The CNA [Certified Nursing Assistant #1] reported a difference in [Named Resident #5]. I got called to look at him, I went in the room, he was different . LPN #2 was asked if she had assessed Resident #5. She stated, .no, I didn't because [Named LPN #1] was assigned to him that night .I just know there was a noticeable decline . Refer to F-580 and F-684. The surveyors verified the Removal Plan by: 1. Beginning on 3/1/2021, chart audits on all residents for the documentation on all acute changes and notification to the Physician, family, and DON/designee were done. The audits were completed on 3/27/2021. The results were reported in the Ad Hoc (as needed) QAPI meeting on 3/27/2021, which included the facility leadership team, Medical Director, and the Governing Body. The surveyors reviewed the chart audits, confirmed the QAPI and Ad Hoc meeting held on 3/27/2021, and interviewed the Administrator and the DON. 2. On 3/27/2021, LPN #1 and LPN #2 were suspended until corrective actions were completed. LPN #1 and LPN #2 were in-serviced on neglect, residents' rights, Quality of Care, notification to the Physician, family, and DON or designee of acute changes in the resident's status, and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the in-services the disciplinary actions for LPN #1 and LPN #2, and interviewed LPN #1. 3. On 3/26/2021, Certified Nursing Assistants (CNA) were in-serviced on communication with Licensed Nurses and change of condition to provide understanding. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed the CNAs on all shifts. 4. On 3/26/2021, Licensed Nurses were in-serviced on abnormal oxygen saturation levels, when to notify the physician and to follow physician orders. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed the Licensed Nurses on all shifts. 5. On 3/12/2021-3/29/2021, Licensed Nurses were in-serviced on notification to the Physician, the DON or designee, and family if the resident had a change in condition. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed Licensed Nurses on all shifts. 6. On 3/12/2021-3/29/2021, Licensed Nurses were in-serviced on monitoring, acute changes, and signs of distress. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed Licensed Nurses on all shifts. 7. Beginning on 3/18/2021, Licensed Nurses received training for signs of [CONDITION(S)]. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed Licensed Nurses on all shifts. 8. On 3/26/2021, all staff were in-serviced on abuse and neglect. Employees must receive initial education prior to the start of their next shift. The surveyors reviewed the in-services and interviewed staff on all shifts. 9. All contract staff and new hires will be provided the additional education on physician notification of changes in resident's condition going forward. The surveyors reviewed the new hire packet and interviewed the Administrator. 10. The DON or designee will complete health document assessments and chart audits every day for 4 weeks, 5 days for 4 weeks, then 3 days for 4 weeks or until 100% substantial compliance, with immediate corrective actions as needed. The surveyors reviewed the health document assessments and chart audits and interviewed the DON. 11. On 3/27/2021, results of audits were included in an Ad Hoc QAPI meeting with the facility leadership team, Medical Director, and Governing Body. The results of audits and any corrective actions will be reported to the monthly QAPI meeting for review of trends and effectiveness regarding preventing neglect, poor quality of care, and failure to provide notifications for the next three months, and Ad Hoc QAPI meetings will also be held as needed. The surveyors reviewed the Ad Hoc QAPI meeting minutes and interviewed the DON. The facility's noncompliance of F-600 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of a Licensed Practical Nurse (LPN) job description, medical record review, and interview, the facility failed to provide the needed care and services timely when LPN #1 and LPN #2 failed to monitor a resident with a noticeable change of responsiveness and a decreased oxygen saturation (O2 sat) (amount of oxygen measured in the blood) level for 1 of 6 sampled residents (Resident #5) reviewed for change in condition, which resulted in Immediate Jeopardy for Resident #5. LPN #1 and LPN #2 failed to provide continued care and ongoing assessments when Resident #5 had an 02 sat of 78-82 percent (%) (normal range is 95-100%). LPN #1 applied 4 liters of oxygen by nasal cannula. The oxygen saturation level remained between 82-85% and Resident #5 had an elevated heart rate and increased respirations. This resulted in Resident #5 remaining without adequate oxygenation for approximately 5 hours and 30 minutes when Resident #5 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON), were notified of the Immediate Jeopardy on 3/26/2021 at 4:34 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-684. The facility was cited at F-684 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 3/10/2021 through 3/28/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/28/2021 at 3:53 PM, and was validated onsite by the surveyors on 3/28/2021-3/29/2021 through policy review, review of the Ad hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, review of audits, review of in-service training records, and interviews. The findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 10/2017, showed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Our facility shall promptly notify the .attending physician .of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .There is a significant change in the resident's physical, mental, or psychosocial status . Review of the LPN Job Description, revised 6/2006, showed, .Provide direct nursing care to residents .in accordance with current Federal, State, and Local standards .to maintain the highest degree of quality care at all times .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .Chart nurses' notes in an informative and descriptive manner that reflects the care provided .Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practice .Notify the resident's attending physician and responsible party when there is a change in the resident's condition .Monitor seriously ill residents .Protect residents from neglect . Review of the closed medical record, showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #5 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 required extensive assistance from 2 staff for all activities of daily living (ADLs) and supervision for meals. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen at ([left blank]) liters [L] per nasal cannula as needed for oxygen saturation less than ([left blank]) .Titrate O2 to keep O2 saturation above or equal to 92%, notify Provider if more than 3 L/min [3 liters per minute] is required .Every 1 hour as needed for shortness of air .[MEDICATION(S)] [inhaler] .Aerosol Solution .2 puffs inhale orally every 4 hours as needed for WHEEZING OR SOB [shortness of breath] . Review of a Progress Note dated 3/10/2021 at 5:08 AM, documented by LPN #1, showed, .at approx. [approximately] 230a [2:30 AM] pt [patient] noted to respond less than normal for pt. pt responding to questions with simple yes and no answers but unable to vocalize more. o2 [O2 sats] decreased to range of 78-82% on room air .hr [heart rate] and resp [respirations] elevated .pt put on o2 at 4 lpm [liters per minute] with minimal effectiveness noted. o2 sat 82-85% hr and resp cont [continue] to be elevated [at] 110-120 bpm [beats per minute] and 22-24 resp .still cannot verbalize more than yes or no answers. pt lying in bed on left side .will cont [continue] to monitor pt status this shift . Review of a Progress Note dated 3/10/2021 at 8:15 AM, documented by Registered Nurse (RN) #1, showed, .Resident very lethargic this morning with a [an] oxygen level of 80% on 5L [liters of oxygen] .Phoned POA [Power of Attorney] but did not get an answer. Phoned seconded [secondary] emergency contact and notified them whom stated they would try to get in touch with POA. Phoned MD [Medical Doctor] who gave the order to send resident out to the hospital .POA called back as EMTs [Emergency Medical Technicians] were arriving .POA was adamant that resident be sent to [Named Hospital]. Informed POA .that he will most likely be sent to [Named Hospital] due to it being closer and [due] to residents [resident's] condition. POA stated understanding. Resident left at approx. 8AM [8:00 AM] via stretcher . Review of the hospital Emergency Visit Note dated 3/10/2021, showed, .presents .with report of altered mental status and [CONDITION(S)] .patient is usually alert and oriented .patient found by staff last night to have decreased alertness and requiring oxygen. O2 sat this morning was in the mid 80s and they called EMS. Patient was placed on oxygen by nonrebreather [special oxygen mask that delivers higher concentrations of oxygen] and oxygen saturation and alertness did improve. Patient is currently on 15 L by nonrebreather and oxygen saturations are 96% .unable to answer any questions .moderate respiratory distress .tachycardia [elevated heart rate] .Oxygen sats maintained on High Flow NC [nasal cannula] at 30 L .admitted to ICU .Clinical Impression: Pneumonia, [CONDITION(S)], Acute UTI [Urinary Tract Infection], Altered Mental Status, [CONDITION(S)] .Condition: Critical . During a telephone interview on 3/19/2021 at 8:55 AM, RN #1 stated, . got report at change of shift [6:30 AM] on 3/10/2021 that he [Resident #5] had a decline .oxygen dropped to low 80's, wasn't responding after O2 placed on him .after report, I went to his room first .the ADON [Assistant Director of Nursing] was already in there [because someone had reported that the resident didn't look good] .his oxygen saturation was low .the ADON changed him to a mask I think it was a nonrebreather, oxygen still not going up .the ADON told me to call POA and Doctor .I made those calls .Doctor gave order to send to ER [emergency room ] . During a telephone interview on 3/19/2021 at 9:54 AM, LPN #1 confirmed that Resident #5 was not his normal self and he could only answer yes and no questions. His oxygen saturation was between 78-82%. LPN #1 confirmed he had applied 4 L of oxygen to Resident #5 and stated, .he didn't get any worse. During an interview on 3/24/2021 at 12:20 PM, the ADON stated, .when I came in to work that morning the Social Worker [SW] stopped me and said will you go look at [Named Resident #5] .heard his oxygen had dropped and they put oxygen on him .I went down and checked on him .oxygen saturation was low .I switched out the BNC [Binasal Cannula] to a mask, he was very lethargic .it was a change in his normal . The ADON was asked if this had happened before with this resident. She stated, .not that I'm aware of . During a telephone interview on 3/24/2021 at 1:10 PM, the Nurse Practitioner (NP) confirmed she had not been notified during the night of Resident #5's acute changes and stated, .if I had been notified of the resident's change, I would have done something . During an interview on 3/24/2021 at 3:48 PM, the DON confirmed the Physician should be notified of changes in residents' condition, decreased oxygen saturation, elevated heart rate, elevated respirations, and stated, I talked with [Named LPN #1] couple of days after about the note just because it was confusing the way the note read .I didn't ask him if he notified the doctor when I talked to him. During a telephone interview on 3/24/2021 at 6:30 PM, LPN #1 confirmed Resident #5 was lethargic, and he had applied oxygen on him and stated, .I monitored him by checking his vitals [blood pressure, pulse, oxygen saturation, and respiration] and asked him how he was doing about every 30 minutes until the end of my shift . LPN #1 confirmed he had not documented Resident #5's vital signs and stated, .he didn't continue to decline so I wasn't that concerned . During a telephone interview on 3/25/2021 at 3:09 PM, LPN #2 confirmed Certified Nursing Assistant (CNA) #1 had notified her of a change in Resident #5's condition, and that she had gone into his room. She stated, .he did not look good. LPN #2 confirmed she did not assess the resident, get vital signs, or notify the Physician, and stated, .no I didn't because [Named LPN #1] was assigned to him that night . During a telephone interview on 3/25/2021 at 3:31 PM, Resident #5's Physician was asked if he was notified about Resident #5's decreased oxygen saturation during the night on 3/10/2021. The Physician stated, No, if I had been notified, I would have sent him out immediately. The Physician was asked if he expected Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 3/25/2021 at 4:18 PM, Firefighter #1 stated, .best I remember when we got there EMS [Emergency Medical Services] was right behind us .[we had] told them to give us a call if they need us .[EMS] waved at us to come help .I jumped in to help .I rode in the back [of the ambulance] .he [Resident #5] was in respiratory distress .pretty acute .working at breathing, had a non-rebreather on plus a nasal cannula .he never said anything, would just stare off .labored breathing .was pale and labored breathing .pulse 130 .respirations 24 . During an interview on 3/26/2021 at 10:33 AM, CNA #1 confirmed that she had taken Resident #5 to the shower and stated, .went in he, [Resident #5] was fine .said hello .he was fine when I took him to the shower he was his normal self .did the next round [checking on residents] .he [Resident #5] wouldn't open his eyes or do anything .that's when I hollered for [Named LPN #1] . CNA #1 was asked what time she noticed a change in Resident #5. CNA #1 stated, It had to be around 2 [2:00 AM] .[Named LPN #1] came in the room and took his vitals .I got out of the way . During an interview on 3/26/2021 at 10:38 AM, LPN #1 confirmed he had taken Resident #5 his medications around 8:00 PM and had no problem. He stated, .took his med [medication] like he normally does .I hadn't been back in there until [Named CNA #1] told me to [check on Resident #5] . LPN #1 was asked when he assessed Resident #5. LPN #1 stated, .checked his vitals .even when his sat [02 sat] fell to the lowest .he still had enough in him to say yes or no .put on oxygen at 4 liters .his 02 [sat] was 82-85% [after O2 applied] . LPN #1 was asked if Resident #5's 02 Sat remained in that range the remainder of the shift. LPN #1 stated, They did. LPN #1 confirmed that LPN #2 had come into Resident #5's room and stated, .she didn't do anything .just had her come in for another set of eyes .she said he had done that before .seems like he was just tired the whole time . LPN #1 was asked if he notified the physician. LPN #1 stated, Nobody. LPN #1 confirmed he should have notified the physician. LPN #1 was asked if there were other treatments on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/27/2021 at 10:49 AM, the DON confirmed that staff should continue to monitor, document, provide additional interventions, notify the physician of acute changes in condition, and should follow Physician Orders. During an interview on 3/27/2021 at 10:49 AM, the Administrator stated, .I wasn't focused .If I had, I would have made sure we looked into it further .I can see the neglect now .the Physician being notified .we would all be in a better position right now .the break down is where the Physician didn't get contacted . Refer to F-600 and F-580. The surveyors verified the Removal Plan by: 1. Beginning 3/1/2021, chart audits for all residents will be completed by 3/27/2021 to ensure all acute changes were documented with notifications to the Physician, family, and DON/designee. Results will be included in an Ad Hoc (as needed) QAPI meeting on 3/27/2021 which included the facility leadership team, Medical Director, and Governing Body. The results will also be reviewed during the Monthly QAPI meeting. The surveyors reviewed the chart audits, Ad Hoc QAPI meeting minutes, and interviewed the DON. 2. On 3/27/2021, disciplinary action was taken with both Licensed Nurses who knew of the significant change but did not report it to the Physician. Education was provided to these employees on neglect, residents rights, notification of acute changes to the Physician, Family, and DON/designee, Quality of Care, and following Physician Orders. On 3/27/2021, both employees were suspended and placed on an action plan for 30 days with monitoring of charting and acute changes. The surveyors reviewed the disciplinary action for both licensed nurses, their in-services, and interviewed LPN #1. 3. On 3/26/2021, education began with the Certified Nursing Assistants (CNA) and must be completed prior to the start of their next shift on change of condition regulations to ensure their understanding and facilitate communication with Licensed Nurses. The surveyors verified the in-services and interviewed the CNAs on all shifts. 4. On 3/26/2021, education began with Licensed Nurses and must be completed prior to the start of their next shift on following Physicians Orders with specifics to applying oxygen, abnormal oxygen saturation levels, and when to notify the physician. The surveyors verified the in-services and interviewed the Licensed Staff on all shifts. 5. On 3/12/2021-3/29/2021, education was completed for Licensed Nurses on notification to the physician, family, and DON/Designee. Education must be completed prior to the start of the next shift. The surveyors reviewed the in-services and interviewed the Licensed Staff on all shifts. 6. Beginning on 3/12/2021, education was provided for Licensed Nurses for monitoring and signs of distress. This education will be completed by 3/29/2021. Education must be completed prior to the start of the next shift. The surveyors reviewed the in-services and interviewed the Licensed Staff on all shifts. 7. Beginning on 3/18/2021, education was provided to all staff on learning specific signs of [CONDITION(S)]. This education will be completed by 3/29/2021. Education must be completed prior to the start of the next shift. The surveyors reviewed the in-services and interviewed staff on all shifts. 8. All of these completed educations will be included for all new hires and contract employees. The surveyors interviewed the Administrator and the DON. 9. The DON/designee will complete chart audits/health document assessment during the morning clinical meeting with 100% resident audit 7 days a week for 4 weeks, 5 days for 4 weeks, and then 3 days for 4 weeks, or until 100% substantial compliance, with immediate corrective actions as needed. The results will be reported in an Ad Hoc QAPI meeting to the facility leadership team, Medical Director, and the Governing Body. Also, for the next three months, audits and corrective actions will be reviewed for effectiveness regarding neglect, failure to provide notification, and poor Quality of Care in the monthly QAPI meeting. Ad Hoc QAPI meetings will also be conducted as needed. The surveyors reviewed the audit forms and interviewed the Administrator and the DON. The facility's noncompliance of F-684 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review and interview, the facility failed to revise the care plan for 1 of 4 sampled residents (Resident #4) reviewed for nutrition. The findings include: Review of the Facility's undated policy titled, Care Plans-Comprehensive, showed .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .The interdisciplinary team will review the attending physician's orders [REDACTED].) and implement a nursing care plan to meet the resident's immediate care needs .Care plans will be modified accordingly . Review of facility's undated policy titled, Weight Monitoring, showed .Based on the resident's comprehensive assessment .the facility will ensure that all residents maintain acceptable parameters of nutritional status . Review of medical record, showed Resident #4 had a [DIAGNOSES REDACTED]. Review of the Care Plan dated 11/19/2020, showed .Monitor/record/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition .significant weight loss .Provide and serve supplements as ordered .RD (Registered Dietitian) to evaluate and make diet change recommendations PRN . Review of the DIETARY RECOMMENDATIONS dated 12/3/2020, showed, .weight loss st (stage) 4 wound .increase house supplement to 120ml (millimeters) TID (three times a day) and record % (percentage) intake in MAR (Medication Administration Record) . Review of Nutrition/Dietary Note dated 12/3/2020, showed, .Noted weight loss of 23.6# (pounds) (13.5%) since admission -40days .Receives House supplement 120ml BID (twice a day) .Recommend to increase to TID .preventing weight loss .promoting wound healing .Supplemental support will help meet needs . Review of DIETARY RECOMMENDATIONS dated 12/3/2020, showed .spoke to resident (Resident #4) on 12/5/2020 he doesn't want to increase his supplements .His P. O. (by mouth) intake has improved . During a phone interview conducted on 12/16/2020 at 2:04 PM, the Family Nurse Practitioner (FNP) confirmed that the recommendations should be carried out so that the facility could agree on and appropriate treatment plan. During a phone interview conducted on 12/16/2020 at 2:45 PM, the Administrator confirmed that Resident #1's Care Plan was not revised for his refusal to increase his house supplements.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a burner stove with thick black carbon build up on the stove eyes, carbon build up in an oven, and 1 of 2 dietary staff (Cook #1) failed to perform hand hygiene with glove use and had facial hair exposed. The facility had a census of 57 residents with 57 of those residents receiving a tray from the kitchen. The findings include: 1. The facility policy titled, Oven .Convection .Gas, dated 12/11/19 documented, .Remove spills, spillovers, and burned food deposits .wash oven interior . The facility policy titled, Stove Top, dated 2/19/15 documented, Wipe off burner grids using clean cloth and detergent .Remove stovetop sections .Take to pot and pan sink and scrub or send through dishmachine . The facility policy titled, PERSONAL HYGIENE/SAFETY/FOOD HANDLING, dated 3/5/19 documnted, .Beards or any body hair that may be exposed .must be covered . The facility policy titled, Handwashing/Hand Hygiene, dated 8/2019 documented, .Use an alcohol-based hand rub containing at least 62% (percent) alcohol .alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .After removing gloves . 2. Observation in the Kitchen on 1/6/20 at 10:48 AM, 1/7/20 at 8:50 AM, and on 1/8/20 at 2:02 PM, showed a stove top with 6 burners with thick black carbon build up and an oven with brown debris and carbon build up. During an interview conducted on 1/8/20 at 2:05 PM, the Dietary Manager was asked if the 6 burner stove was clean. The Dietary Manager stated, Build up. She confirmed carbon build up on the 6 burner stove. The Dietary Manager was asked about the oven. She stated, Does not appear to be clean. 3. Observation in the Kitchen on 1/6/20 at 10:49 AM, showed Cook #1's beard and mustache was not completely covered. Observation in the 200 Hall on 1/6/20 at 12:05 PM, showed Cook #1's beard and mustache was not completely covered as he served lunch plates. Observation in the 300 Hall on 1/6/20 at 12:14 PM, showed Cook #1 checked the food temperatures, removed his gloves, and donned new gloves without performing hand hygiene. Observation in the Kitchen on 1/7/20 at 8:50 AM, showed Cook #1's beard and mustache was not completely covered. During an interview conducted on 1/8/20 at 2:15 PM, the Dietary Manager was asked about facial hair in the kitchen. The Dietary Manager stated, I would expect all of the hair should be covered. During an interview conducted on 1/9/20 at 8:50 AM, the Registered Dietician (RD) was asked what she expected staff to do between removing and donning gloves. The RD stated, Wash their hands.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #1) remained with a resident during an inhalation treatment for 1 of 10 sampled residents (Resident #32) observed during medication administration. The findings include: The facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010 documented, .Remain with the resident for the treatment . Review of the medical record, showed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] SUL (Sulfate) 1.25 MG (milligram)/ (per) 3ML (milliliters) SOL. (solution) GIVE ONE PER NEBULIZER EVERY 4 HOURS . Observation in the resident's room on 1/7/20 at 8:06 AM, showed LPN #1 administered the [MEDICATION NAME] nebulizer treatment to Resident #32. LPN #1 left the room and was absent during the entire treatment. The facility was unable to provide a self-administration assessment for nebulizer treatments for Resident #32. During an interview conducted on 1/8/20 at 4:07 PM, the Director of Nursing confirmed the nurse should stay with the resident during the breathing treatment unless the resident has had a self-administration assessment.

Based on medical record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 18 sampled residents (Resident #56) reviewed. The findings include: Review of the medical record, showed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Order Date 10/10/19 .Start Date 10/10/19 .ADMIT TO HOSPICE SERVICES WITH (Named Hospice Company) . Review of the medical record, showed there was no Significant Change MDS assessment completed when Resident #56 was referred to hospice services. During an interview conducted on 1/6/20 at 2:15 PM, the MDS Coordinator confirmed Resident #56 should have had a significant change MDS assessment done when hospice services were ordered.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 6 (Resident #1) cognitively impaired, vulnerable sampled residents reviewed who had elopement behaviors/risk. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with known wandering behavior, who was missing for approximately 2 hours from the facility before the staff realized she had eloped from the facility. Resident #1 had eloped from the facility and was not located until approximately 4.5 hours later when she was found lying in a creek embankment containing water and suffered from hypothermia (dangerously low body temperature) and hematoma (swelling and bruising) around her right eye. This resulted in an IJ for Resident #1. The facility identified 9 cognitively impaired residents who were independently mobile via ambulation or wheelchair with wandering behaviors. The facility reported a total census of 57 residents. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Wandering, Unsafe Resident policy, undated documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included . Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker with ambulation. The Baseline Care Plan dated 3/12/19 documented, .PROBLEM Date: 3/12/19 I am at risk for elopement as evidenced by .Wandering .Other encephalitis (symbol for increased) agitation (symbol for increased) confusion Ambulatory .3-18-19 - Elopement - Resident Sent to ER (emergency room ) c (with) minor injuries . Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review included the following notes that documented Resident #1 displayed impaired cognitive status. A Nurse's Note dated 3/14/19 3:36 AM documented, .Some confusion . A Nurse's Note dated 3/14/19 4:40 PM documented, .Some confusion noted . A Nurse's Note dated 3/14/19 11:53 PM documented, Resident up in room rearranging belongings. Stated she got OOB (out of bed) at 6:00 pm thinking her son was coming to take her to get her mail but he did not come .Up in the hall requesting toilet paper, but some was found to be already in place in her room . A Nurse's Note dated 3/17/19 3:13 PM documented, .increased confusion. When helping resident get dressed this morning resident kept attempting to put her shirt on as her pants. Walked out of her room several times asking for the bathroom .Wandering into residents room and pushing on exit door handles . A Nurse's Note dated 3/18/19 6:10 AM (late entry) documented, Pt (patient) not in her (Resident #1's) room all rooms searched completely .Police notified and given information of incident . A Police Department incident report dated 3/18/19 at 3:01 AM to 4:45 AM documented, (Named Nurse and Certified Nursing Assistant (CNA)) informed officers that (Resident #1) left the facility between 0000-0030 (12:00 AM-12:30 AM) hours .last seen wearing a pink sweatshirt, blue pants, possibly wearing slippers, and suffers from dementia .stated (Resident #1) had been wandering around all-night in the hallway .0331 (3:31 AM) hours EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) hours - K9 began track Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. A telephone interview with Certified Nursing Assistant (CNA) #1 on 3/21/19 at 1:30 PM, CNA #1 was asked when was the last time she saw Resident #1. CNA #1 stated, I saw her about 12:15 (AM). Took her to her room, put her to bed and closed the door . Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Registered Nurse (RN #1) on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked when was the last time she saw Resident #1. RN #1 stated, Can't recall exact time I last saw her. She was going in other rooms and coming in/out hallway .Just thought I'd check in on her. It was 2:00 AM. Checked the room. Asked (named CNA) if she had seen her leave . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 was asked when was the last time she saw Resident #1. CNA #2 stated, I saw her going down the hall .about 12:15 AM. I went back to my hall on 300 . CNA #2 was asked if she heard any door alarms sounding that night. CNA #1 stated, No . A telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I heated up my meal in the breakroom across from the nurses' station. Nobody was particularly watching the room. I went about 1:30 (AM) and helped (named CNA). I had a light going off I went and answered the lights. Went to the bathroom a couple of times. CNA #1 was asked who was monitoring the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . The facility failed to ensure a safe environment for Resident #1 when they had no knowledge of her location for approximately 4.5 hours. Resident #1 had been assessed and documented as cognitively impaired with risk for elopement as evidenced by wandering behaviors and eloped from the facility on 3/18/19. She was found 4.5 hours later on 3/18/19 lying in a creek embankment containing water. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: A. A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. G. Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. J. DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: A. Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. G. Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.

Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 6 (Resident #1) residents reviewed, which resulted in Resident #1 exiting the facility, was found sitting in a creek containing water and sustained hypothermia (dangerously low body temperature) and a hematoma (swelling and bruising)around her right eye. The facility's failure to prevent neglect placed Resident #1 in Immediate Jeopardy (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). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The Wandering, Unsafe Resident policy, revised (MONTH) 2014 documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, was ambulatory with an unsteady gait and used a walker, and wandering occurred 1-3 days of the assessment period. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM documented, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. Emergency Management Agency and Search and Rescue Dog (K9) responded. At approximately 4:45 AM, Resident #1 was found sitting in a creek embankment containing water by Emergency Management Services and was transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) . Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . The (Named) Police Department (PD) report number documented, .3/18/19 at approximately 0304 (3:04 AM) hours dispatched to a missing person endangered .Nursing staff and officers searched the facility and immediate areas .0331 (3:31 AM) hrs (hours) EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) K9 began track .As we were tracking (Resident #1's) scent, we were notified that (Resident #1) was seen lying in the embankment. Once verified that it was (Resident #1), she was transported by EMS (Emergency Management Services) to (named hospital) . Observations on 3/21/19 and 4/22/19 revealed the facility had 7 entrance/exit doors with keypads that required a code to open or enter/exit: 1 Front Main entrance/exit doorway; 1 Dining Room exit doorway; 1 100 hall end of hall exit doorway; 1 patio entrance/exit doorway; 1 200 hall end of hall exit doorway; 1 300 hall vending machine entrance/exit doorway visible from the nurse's station; 1 300 hall end of hall exit doorway. Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Certified Nursing Assistant (CNA) #4 on 4/22/19 at 1:34 AM, in the 300 hallway, CNA #4 was asked if she sat in the hallway most nights. CNA #4 stated, Yeah, we all do when we finish rounds . CNA #4 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning 3/17/19. CNA #4 stated, No. I didn't. Interview with the Maintenance Director on 4/22/19 at 4:20 PM in the Family Room, the Maintenance Director confirmed the Front Main entrance door code had been posted on the code box beside the door both at the entrance and exit code box .on that day (3/18/19) I immediately came in around 5:30 (AM) and checked all exit doors to verify working properly .I pulled open every code box at the exit doors and checked the wiring to make sure working properly .All batteries were working properly, however I went ahead and ordered all new batteries and .replaced all batteries in every code box .I then went into the ceiling above 200 hall exit door and opened the junction box and made sure all wiring was correct and tight, the wiring was working but it was discolored so I replaced it over the 200 hall exit door .I inserviced all day and night shift staff of the elopement policy and procedure and we did .drill (elopement scenario) for each shift . Interview with Licensed Practical Nurse (LPN) #1 on 4/22/19 at 4:52 PM, in the Family Room, LPN #1 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning on 3/17/19. LPN #1 stated, I don't recall any alarms going off. LPN #1 stated, No, I was at the desk. LPN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. LPN #1 stated, No. Interview with Registered Nurse (RN) #1 on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked if she heard any door alarms sounding. RN #1 stated, Not that I recall. RN #1 was asked if she watched the 200 hall while CNA #1 was helping on the other hall. RN #1 stated, I watched for call lights. RN #1 was asked if she could see down the hall. RN #1 stated, No, I was at the desk. RN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. RN #1 stated, No. RN #1 confirmed her witness statement. RN #1 stated, .That night (named Resident #1) had been up and down the (200) hallway .At 2:00 AM I peeked in her (Resident #1) room to check on her and she was not in her room .I asked (named CNA #1) did you see her leave her room and she said no .I then told all staff to begin searching in all rooms, bathrooms, closets everywhere as well as outside . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 stated, I saw (Named Resident #1) going down the hall, 200 hall .directed her back into her room about 12:15 (AM). I went back to my hall on 300. CNA #2 was asked if she heard any door alarms sounding that night. She stated, No. CNA #2 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #2 stated, No. Interview with CNA #3 on 4/22/19 at 7:05 PM, in the Family room, CNA #3 stated, I asked (Named CNA #1) to help me with a resident on 100 hall around 1:30 (AM). She came to room [ROOM NUMBER] .She left the room after 15 to 20 minutes . CNA #3 was asked if she heard any door alarms sounding that night. She stated, No. CNA #3 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #3 stated, No. Telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I ate my meal between 12 (AM) and 1(AM). Meal was in the breakroom. I heated it up in the breakroom across from the nurses' station. Nobody was particularly watching the room (Resident #1's room). Others were watching for lights (resident call lights) or listening for the lights. I left to help (Named a CNA) for about 10 minutes. I did rounds. She (Resident #1) was by her door. I directed her back in her room. I finished my round, probably 4 people, and 2 rooms. Then went and heated my meal. I had a light going off. I went and answered the lights. Went to the bathroom a couple of times. Her door was shut. CNA #1 was asked who was monitoring the hall, particularly Resident #1's room, while she was off the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No .CNA #1 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #1 stated, No .saw her (Resident #1) wander out of her room and down the hall toward the nurses' station or walk in her room . A second telephone interview with CNA #1 on 4/22/19 at 7:30 PM, CNA #1 confirmed her witness statement. She stated, .The last time I saw (named Resident #1) was approximately 12:15 AM. I redirected her back to her room. She said she was going to bed and closed the door .At approximately 2:00 AM the nurse (RN #1) said (named Resident #1) was not in her room, did I know where she was .that is when we started searching the facility and the grounds . Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . Record review of maintenance records of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system dated 3/6/19 - 4/17/19 revealed, the logs were completed weekly and passed inspection. Review of the Emergency Power Generators logbook dated 3/8/19 - 4/16/19 were completed weekly and passed inspection. The facility's failure to monitor and supervise a cognitively impaired resident resulted in Resident #1 wandering away from the facility during the night and suffering from hypothermia and a hematoma around her right eye. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: A. A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. G. Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. J. DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19 - 4/24/19 as follows: A. Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. G. Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.

Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of neglect to the State Survey Agency timely for 1 of 6 (Resident #1) residents reviewed for neglect. Resident #1 eloped and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure to report neglect timely placed Resident #1 in Immediate Jeopardy (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). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Abuse Prevention Policy & Procedure, revised 2/26/18 documented, .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker when ambulating. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM revealed, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 4:45 AM, Resident #1 was found lying in a creek embankment containing water and transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) .Hematoma (bruising and swelling) around the right eye . Interview with the DON on 3/21/19 at 2:55 PM in the Family Room, the DON stated, .The Administrator reported (the incident to the State) that morning after she (Resident #1) was taken to the ER (emergency room ) . Interview with the Administrator on 4/22/19 at 2:00 AM in the Family Room, the Administrator stated, .I was notified 3:13 (AM) by phone from the night shift RN (Registered Nurse) a resident had eloped .I called the DON to inform her of the elopement . Review of the facility self-report revealed the incident was reported to the state survey agency on the morning of 3/18/19 (at 7:13 AM approximately 5 hrs and 13 minutes after the incident). The facility's corrective action plan included the following: On 3/18/19 the facility did the following: A. A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. G. Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. J. DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: A. Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. G. Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.

Based on policy review, medical record review, and interview, the facility failed to prevent accidents related to falls for 1 of 12 (Resident #30) residents when fall interventions were not implemented. The findings include: The facility's Falls and Fall Risk, Managing policy revised on 3/2018 documented, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/1/17 documented, .9/24/18 Rojo (pressure relieving) cushion to wheelchair .12/26/18-Educate R/T (related to) proper cushion and placement in w/c (wheelchair) .1/14/19 Fall-Ensure dysem is in w/c (wheelchair) staff education . Review of the facility's Resident Incident Report dated 12/26/18 documented, .leaning forward and slid out .wc (wheelchair) .cushion eval (evaluated) improper cushion in place .new Rojo (pressure relieving cushion) being ordered .a fall without injury . Review of the facility's Resident Incident Report dated 1/14/19 documented, .found lying on floor in front of wheelchair .care planned to have dycem to wc (wheelchair) .was not present .no injury . Interview with the Director of Nursing (DON) on 2/21/19 at 3:58 PM, in the Family Room, the DON was asked if the interventions were in place for Resident #30's falls on 12/26/18 and 1/14/19. The DON stated, No, they were not in place.

Based on policy review, medical record review, review of incident reports, observation and interview, it was determined the facility failed to follow care plan intervention to prevent falls with injury for 1 of 3 (Resident #1) sampled residents with falls. The staff failed to follow the care plan intervention of two person assist which resulted in two falls with injury. Fall #1 resulted in skin tears and a fractured hip and fall #2 resulted a hematoma to the head causing actual harm to Resident #1. The findings included: Review of the facility's "Falls Management" policy documented, "...Policy: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program... The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injury... Implement the Plan of Care..." Medical record review for Resident #1 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/21/13 and the care plan dated 8/7/14 documented, "...Problem Onset: 12/25/2009... Potential for skin breakdown r/t (related to) two person extensive assistance with bed mobility... Resident is at risk for spontaneous pathological fractures due to Dx (diagnosis) of Osteoporosis... Approaches... Transfer with Hoyer lift x (time) 2 persons... 2 persons for mobility, ADL's (activities of daily living), and transfers..." Review of the nurses' notes dated 1/16/14 documented, "...During a.m (morning) ADL's resident rolled out of bed. Two s/t (skin tears) to (R) (right) elbow... No other apparent injury to resident..." Review of the nurses' notes dated 1/17/14 documented, "...During ADL's resident had s/s (signs and symptoms) of pain while turning. Physician notified and x-ray ordered of hip/thigh. Results of x-ray Acute intertrochometer fx (fracture)..." Review of the "Resident Incident Report" dated 1/16/14 documented, "...While CNA (Certified Nursing Assistant) performing A.M. ADL's, she rolled resident over and resident rolled out of bed..." Review of a radiology report dated 1/17/14 documented, "...There is a comminuted... fracture the right hip..." Review of the (Named Hospital) History and Physical dated 1/20/14 documented, "...The patient had been doing well until the end of last week when she rolled partially out of bed. Twenty-four hours later she was noted to be more uncomfortable. X-ray was done of her right hip, which showed intertrochanteric displaced fracture. It was decided by the family at that time they did not wish to have her hospitalized though they understood that she could have a fair amount of pain. Unfortunately, over the weekend, her pain continued to be an issue, and the family reconsidered..." Review of the nurses' notes dated 7/8/14 documented, "...transferring resident to chair by writer using a lift assisting device when somehow slid in the sling and fell on the floor... has a 6" (inch) x (by) 4" knot on top of the head... was transferred to (Named) ER (emergency room )..." Review of the "Resident Incident Report" dated 7/8/14 documented, "...Resident was transferring to chair by nurse using a lift assist... As I was lifting resident somehow one of her legs got with her other leg and slid out and fell , In that process she hit her head on the bed frame..." Review of the (Named Hospital) History and Physical dated 7/8/14 documented, "...The patient apparently had been moved in a Hoyer lift when she fell out of it hitting her head... a CAT (Computerized Tomography) scan was done which revealed the patient had moderate right parietal scalp swelling with associated hematoma..." Review of the CAT scan report dated 7/8/14 documented, "...IMPRESSION... Moderate to marked RIGHT parietal scalp swelling, scalp hematoma..." Observations in Resident #1's room on 8/18/14 at 11:40 AM, 3:10 PM and 4:45 PM and on 8/19/14 at 7:50 AM, revealed Resident #1 lying in bed. Resident #1 did not answer questions. During an interview in the Director of Nursing's (DON) office on 8/19/14 at 11:00 AM, the DON was asked if the care plan dated 2/21/13 was in effect for these falls. The DON stated, "Yes." During a telephone interview in the Administrator's office on 8/19/14 at 2:40 PM, CNA #2 was asked about Resident #1's fall on 1/16/14. CNA #2 stated as she was providing ADL care, she went to turn Resident #1, and she (Resident #1) rolled out of bed. CNA #2 stated she was the only CNA in the room assisting this resident. CNA #2 was asked if she normally assisted Resident #1 with ADL care alone. CNA #2 stated when she first started caring for this resident, she would get someone to help her, but as she became more used to the resident and that assignment, she would try to do unassisted. CNA #2 was asked if she was aware the resident was to be 2 person assist according to the care plan. CNA #2 stated, "At that time, I did not know that. I had not looked in the computer for the care plan." During an interview in the family room on 8/19/14 at 4:55 PM, Nurse #2 was asked about Resident #1's fall on 7/8/14. Nurse #2 stated it was about lunch time, Resident #1 was receiving a different mattress, and the mattress technician was delivering the mattress. As i was trying to get Resident #1 in the sling of the lift, she was kicking both legs together, and slid to the bed and floor. Nurse #2 was asked why he was the only one assisting Resident #1. Nurse #2 stated, "They (staff) said should have been 2 people. I did not check the kiosk, should have been 2 people. I am sorry, should have been 2 (person assist)." During an interview in the family room on 8/19/14 at 5:20 PM, the DON stated, "After this fall, did transfer assessments on all residents as a part of my plan of correction... moved her (Resident #1) up to a 3 person assist..." The staff failed to follow the care plan intervention of two person assist which resulted in two falls with injury. Fall #1 resulted in skin tears and a fractured hip and fall #2 resulted a hematoma to the head causing actual harm to Resident #1.

Based on medical record review, review of incident reports, observation and interview, it was determined the facility failed to ensure care plan interventions were followed for falls for 1 of 17 (Resident #1) sampled residents. The staff failed to follow the care plan intervention of two person assist which resulted in two falls with injury. Fall #1 resulted in a [MEDICAL CONDITION] and fall #2 resulted a hematoma to the head causing actual harm to Resident #1. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/21/13 and the care plan dated 8/7/14 documented, "...Problem Onset: 12/25/2009... Potential for skin breakdown r/t (related to) two person extensive assistance with bed mobility... Resident is at risk for spontaneous pathological fractures due to Dx (diagnosis) of [MEDICAL CONDITION] Approaches... Transfer with Hoyer lift x (time) 2 persons... 2 persons for mobility, ADL's (activities of daily living), and transfers..." Review of the nurses' notes dated 1/16/14 documented, "...During a.m (morning) ADL's resident rolled out of bed. Two s/t (skin tears) to (R) (right) elbow... No other apparent injury to resident..." Review of the nurses' notes dated 1/17/14 documented, "...During ADL's resident had s/s (signs and symptoms) of pain while turning. Physician notified and x-ray ordered of hip/thigh. Results of x-ray Acute intertrochometer fx (fracture)..." Review of the "Resident Incident Report" dated 1/16/14 documented, "...While CNA (Certified Nursing Assistant) performing A.M. ADL's, she rolled resident over and resident rolled out of bed..." Review of a radiology report dated 1/17/14 documented, "...There is a comminuted... fracture the right hip..." Review of the (Named Hospital) History and Physical dated 1/20/14 documented, "...The patient had been doing well until the end of last week when she rolled partially out of bed. Twenty-four hours later she was noted to be more uncomfortable. X-ray was done of her right hip, which showed intertrochanteric displaced fracture. It was decided by the family at that time they did not wish to have her hospitalized though they understood that she could have a fair amount of pain. Unfortunately, over the weekend, her pain continued to be an issue, and the family reconsidered..." Review of the nurses' notes dated 7/8/14 documented, "...transferring resident to chair by writer using a lift assisting device when somehow slid in the sling and fell on the floor... has a 6" (inch) x (by) 4" knot on top of the head... was transferred to (Named) ER (emergency room )..." Review of the "Resident Incident Report" dated 7/8/14 documented, "...Resident was transferring to chair by nurse using a lift assist... As I was lifting resident somehow one of her legs got with her other leg and slid out and fell , In that process she hit her head on the bed frame..." Review of the (Named Hospital) History and Physical dated 7/8/14 documented, "...The patient apparently had been moved in a Hoyer lift when she fell out of it hitting her head... a CAT (Computerized Tomography) scan was done which revealed the patient had moderate right parietal scalp swelling with associated hematoma..." Review of the CAT scan report dated 7/8/14 documented, "...IMPRESSION... Moderate to marked RIGHT parietal scalp swelling, scalp hematoma..." Observations in Resident #1's room on 8/18/14 at 11:40 AM, 3:10 PM and 4:45 PM and on 8/19/14 at 7:50 AM, revealed Resident #1 lying in bed. Resident #1 did not answer questions. During an interview in the Director of Nursing's (DON) office on 8/19/14 at 11:00 AM, the DON was asked if the care plan dated 2/21/13 was in effect for these falls. The DON stated, "Yes." During a phone interview in the Administrator's office on 8/19/14 at 2:40 PM, CNA #2 was asked about Resident #1's 1/16/14 fall. CNA #2 stated as she was providing ADL care, she went to turn Resident #1, and she rolled out of bed. CNA #2 stated she was the only CNA in the room assisting this resident. CNA #2 was asked if she normally assisted Resident #1 with ADL care alone. CNA #2 stated when she first started caring for this resident, she would get someone to help her, but as she became more used to the resident and that assignment, she would try to do unassisted. CNA #2 was asked if she was aware Resident #1 was to be 2 person assist according to the care plan. CNA #2 stated, "At that time, I did not know that. I had not looked in the computer for the care plan." During an interview in the family room on 8/19/14 at 4:55 PM, Nurse #2 was asked about Resident #1's fall on 7/8/14. Nurse #2 stated it was about lunch time, Resident #1 was receiving a different mattress, and the mattress technician was delivering the mattress. As I was trying to get Resident #1 in the sling of the lift, she was kicking both legs together, and slid to the bed and floor. Nurse #2 was asked why he was the only one assisting Resident #1. Nurse #2 stated, "They (staff) said should have been 2 people. I did not check the kiosk, should have been 2 people. I am sorry, should have been 2 (people assist)." During an interview in the family room on 8/19/14 at 5:20 PM, the DON stated, "After this fall, did transfer assessments on all residents as a part of my plan of correction... moved her (Resident #1) up to a 3 person assist..." The staff failed to follow the care plan intervention of two person assist which resulted in two falls with injury. Fall #1 resulted in a [MEDICAL CONDITION] and fall #2 resulted a hematoma to the head causing actual harm to Resident #1.