Every finding on record at Gardens Nursing and Rehab Center

Based on observations, interviews, and record reviews it was determined that the facility did not ensure the resident call system functioned properly, nor did it maintain a reliable communication system for residents to request staff assistance from their rooms (including bathrooms) to a centralized staff work area on one (third) of the three floors where residents resided. Four residents (Resident #46, Resident #12, Resident #16, and Resident #52) out of the fifty-three residing on the third floor reported that the call system was not working. The findings included: During an observation conducted on 03/23/2026 at 9:10 AM, Resident # 16 reported the call light has not worked for over a month and maintenance staff reported it was an issue with the electrical outlets. Record review for Resident # 16 revealed the resident was admitted to the facility on [DATE], with the diagnosis that include Encephalopathy; Type 2 Diabetes Mellitus with others Specified Complication. Review of the Annual Minimum Data Set (MDS) dated [DATE] cognitive section documented a BIMS (Brief Interview for Mental Status) score of 13 out of 15 indicating no cognitive impairment. Inspection of the call light system in Resident #16's bathroom revealed when activated the call light did not light up in the bathroom or outside of the resident's room to notify staff that Resident #16 required assistance. Further observation revealed that while the bathroom call system was activated, no auditory was heard at the nurses' station. Record review for Resident # 46 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Other Neuromuscular Dysfunction of Bladder. Resident # 46 Quarterly MDS dated [DATE].cognitive section documented a BIMS summary score of 15 out of 15 indicating the resident is cognitively intact. Interview on 03/23/2025 at 9:35 AM Resident # 46. reported that there has been no call light in the room since admission to the facility. The resident stated that when assistance is needed, they resort to screaming, and sometimes nursing staff respond. Record review of Resident #52 clinical records revealed the resident was admitted on [DATE] with medical diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. Quarterly Minimum Date Set (MDS) dated [DATE] cognitive section indicated Resident # 52 had a Brief Interview of Mental Status (BIMS) summary score of 15 out of 15 indicating the resident is cognitively intact. In an interview conducted on 03/23/2026 at 10:10 AM, Resident # 52 revealed the call light had not been working for a long time and when assistance is needed, he waits for someone to enter the room. Resident # 52 then proceeded to press the call light button noted at the end of the call light cord. No light was noted outside Resident # 52's room and no light nor sound was noted in the nurse station to alert staff that the call light was activated in Resident # 52's room. Further observation revealed no staff checked in Resident # 52' s room up to 30 minutes later at 10:40 AM, and no staff came into the room an hour later at 11:30 AM. In an observation conducted on 03/23/2026 at 10:50 AM, in Resident # 12's room, the surveyor used the call light noted on the bed to call for assistance. No light was noted outside the room to notify staff that the call light was used to call for assistance. Further observation revealed no light activated at the nurses' station to alert staff that the call light was used in Resident #12's room. During an interview conducted on 03/23/2026 at 10:30 AM, Staff N Registered Nurse revealed when a resident uses the call light to call for assistance, a light should go on outside the room, indicating that the resident needs help and also at the nurse 's station, indicating the room number that the call light was used. On 03/23/2026 at 11:38 AM Staff L, Certified Nursing Assistant stated: We have a person checking the room every 15 minutes, a different person is assigned every day, I can't put a finger on how many months it's been, but there is a log where they record when they go into the rooms. On 03/25/2026 at 1:41 AM, the Director of Environmental Services reported that before he started working in the facility seven months ago, there was an estimate for repairs to the call lights. He is aware that CNAs are supposed to do 15-minute rounds. He noted that the call lights for the bathroom and the entire third floor are not working and that he can call corporate to check when they will be fixed. Currently, there is no set time for these repairs, including the bathroom call lights. On 03/26/2026 at 9:21 AM the Director of Environmental Services revealed the call light estimate was given to corporate on the same day dated on estimate form, and they had not got back about that, and he believes administrator has called once or twice about it. On 03/26/2026 at 5:50 PM the Administrator revealed the second floor currently operates on a wireless call bell system, with noted challenges related to internet reliability despite backup measures. Plans include exploring repairs using existing system components or transitioning them into a more reliable solution. The third floor is in the process of obtaining estimates and awaiting a few other companies to get back. We have a 15-minute rounds establish, and they are all documented in a log in the nurse station. Review of the Policies and Procedures for call lights, Effective Date: 09/01/2024 Policy: The purpose of this policy is to ensure residents' requests and needs are responded to. Procedure: Call light should be within reach of the resident Answer the residents' call as soon as possible Report malfunctioning call lights to Maintenance, ED, and/or DON promptly Offer stationary bells and/or round frequently on residents if the call light system is malfunctioning.

Based on observations, record reviews, and interviews, it was determined that the facility did not adequately protect one of two sampled residents from sexual abuse. According to a Federal report, on 03/17/2026, vulnerable Resident #32 was sexually assaulted by Resident # 6, who has a documented history of sexually inappropriate conduct toward staff and other residents. At the time of the survey, 112 residents resided in the facility. The findings included:On 03/23/2026 at 9:05 AM Resident # 32 was observed in her room sitting on the side of the bed and stated, I want bathroom. The call system did not work, so the surveyor notified a staff member that the resident needed help.Record review of a Federal Report revealed on 03/17/2026 at 6:07 PM Resident #32 was observed by facility staff in bed with Resident #6 on top of Resident #32. At that time Resident # 32 was not wearing a brief. Further review of report revealed Resident # 32 was sent out to the hospital for a Rape Kit and Sexual Transmitted Disease test to be conducted as a precaution.Review of the hospital's summary report revealed Resident # 32 was admitted for medical clearance following a suspected sexual battery.Review of Resident #32's hospital flowsheets revealed orders for antibiotics Doxycycline 100 milligram (mg) twice a day and Metronidazole 500 mg tablet every 8 hours on 03/19/2026 as prophylaxis treatment.Review of Resident # 32's Hospital Discharge Needs and Care Plan; Post-Hospital Care Requirements revealed Resident #32 required ongoing monitoring and prophylaxis following the suspected assault alongside management of her chronic conditions. Post-Exposure Prophylaxis completion of the initiated medication regimen for infection prevention.Record review of Resident # 32's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included Alzheimer's Disease, Psychosis, Cerebral Infarction, Depressive episode and Mood [AFFECTIVE] Disorder.Record review of a Quarterly Minimum Data Set (MDS) reference dated 03/1/2026 revealed Resident # 32 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment and was independent for toileting hygiene and transferring.Record review of a care plan initiated on 03/24/2026 revealed Resident # 32 had depression related to (r/t) depressive disorder, unspecified mood disorder with interventions that included: Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness, any signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness, the resident needs time to talk and encourage the resident to express feelings.Record review of a nursing note dated 03/17/2026 timestamped 8:13 PM revealed Resident # 32 was found in bed at 5:30 PM alert and disoriented unable to explain. No visible injury or findings vital signs. Supervisor and Medical Doctor (MD) notified. incident reported per facility protocol. Resident monitored closely.Record review of a nursing note dated 03/17/2026 timestamped 11:04 PM revealed Resident # 32 was alert and responsive to all stimuli. No signs of distress noted. MD gave orders to transfer resident to nearby hospital diagnosis Sexual Battery. Family made aware.Record review of a nursing note dated 03/17/2026 timestamped 11:40 PM revealed Resident # 32 was transferred to a nearby hospital via non-emergency ambulance company accompanied by two attendants.On 03/24/2026 at 9:28 AM, the Registered Nurse (RN) Supervisor stated: In the evening (03/17/2026) [Staff D, RN] called me to the room and told me [Resident # 32] was observed in bed, while [Resident # 6] was standing by the bed making thrusting movements towards [Resident # 32]. I called the physician, family and 911 emergency services. When the police arrived, they did not make any arrests due to no physical evidence found.During a phone interview on 03/24/2026 at 11:42 AM Resident # 32's son stated: I am aware of the incident that occurred. On that day I was called by a nurse and told that another resident was in my mother's room with pants down and my mother had no incontinent brief on. When I arrived at the facility, I received a different story; they said the male resident was on top of my mother doing his thing. When I spoke to my mother, she told me it's not the first time. My mother complained of a stomachache. If nothing happened, why would they give my mother all these tests?Interview on 03/24/2026 at 3:06 PM the Social Services Director stated: I spoke with the abuse hotline, and the person told me they did not accept the case. They did not give me any physical confirmation. Interview on 03/24/2026 at 3:15 PM Staff G, Certified Nursing Assistant (translated by other surveyor) revealed during rounds Resident #32 was in bed and Resident # 6 was on top of Resident # 32 making a thrusting movement. I didn't see any penetration; I saw the brief belonging to [Resident #32] on the floor. I tried to pull Resident #6 away and yelled help. On 03/24/2026 at 3:55 PM, the Director of Nursing (DON) stated, On the day of the incident I received a phone call from the RN supervisor stating [Resident #6] was found humping [Resident # 32]. The details were Staff G, CNA reported [Resident # 6] was wearing clothes and was making movements on [Resident # 32] who did not have on a brief. I informed the Administrator and instructed for a nursing assessment to be done on [Resident # 32]. I instructed staff to separate the two residents. I told the Social Services Director (SSD) to call the abuse hotline. The SSD told me that the staff are giving two different stories. I instructed [Staff D, CNA] to write exactly what was witnessed. A police detective came and did not arrest anyone. I instructed staff to call 911 for [Resident # 32] to get tested for STDs (Sexually Transmitted Diseases). [Resident # 32] was taken to the hospital.During an interview on 03/24/2026 at 4:28 PM Resident # 46 (Resident # 6's previous roommate) stated: [Resident # 6] told me he only looked under [Resident # 32's] dress but did not touch [Resident # 32]. On 03/24/2026 at 4:35 PM Resident # 32 was observed in the room lying in bed. Resident # 32 was interviewed (translated by another surveyor) and was unable to answer questions.On 03/23/2026 at 9:15 AM Resident # 6 was observed in his room with a 1:1(one to one) monitor at bedside.Review of Resident # 6's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Paranoid Schizophrenia, Generalized Anxiety Disorder and Other depressive episodes.Review of the Quarterly Minimum Data Set, dated [DATE] indicate a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating Resident # 6 is cognitively intact.Record review of a Care plan initiated on 05/13/2025 and revised on: 03/24/2026 revealed Resident # 6 had behavior problem related to curses, noncompliance with treatment regimen. inappropriate sexual behaviors toward staff and other residents. Resident exhibits sexual inappropriate behavior toward another resident. Interventions included: Encourage the resident to express feelings appropriately. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Provide 1:1 supervision as much as possible.Record review of Psychiatric notes dated 03/18/2026, 02/10/2026 and 12/3/2025 indicated Resident # 6 had diagnosis of depression, psychosis, anxiety, and paranoid schizophrenia.During an observation and interview on 03/24/2026 at 4:42 PM Resident # 6 was in his room with a 1:1 monitor at bedside. Resident # 6 revealed: I went into [Resident # 32's] room to use the restroom because mine was broken. I had been using [Resident # 32's] bathroom all day. I saw [Resident #32] needed help to get on the bed, so I tried to help. I have helped other female residents by covering their breasts when exposed.Interview on 03/25/2026 at 9:41 AM Resident # 34 stated, [Resident # 6] exposed his genitals to me once about a week ago. I don't feel staff are observant enough.On 03/25/2026 at 9:50 AM Resident # 84 stated: Male residents have entered my room without my consent on a daily basis. I easily redirect them with a look and they don't bother me. I try to keep to myself because it's wild in the facility. I have told staff many times. The only reason it hasn't happened to me is because you are here. On 03/25/2026 at 10:10 AM Staff H, CNA stated, I am the 1:1 monitor for [Resident # 6], and he exposed his genitals to me several times in the past. The last time being a month ago and I have let administration know. Since he has been on 1:1 monitoring he has not been inappropriate with me.On 03/25/2026 at 10:18 AM, during an interview with the DON regarding Resident # 6's history of inappropriate behavior toward other residents and staff, the DON confirmed that the facility's administration and staff had acknowledged Resident #6's actions of exposing his genitals and masturbating in front of staff and other residents. During a telephone interview on 03/25/2026 at 1:59 PM, the Psychiatrist stated: I assessed [Resident # 32] with a Creole speaking nurse and found [Resident # 32] to be so demented that there was no recollection of the incident. There has been no major change in [Resident # 32's] psychological state compared to before the incident. Interview on 03/25/2026 at 5:25 PM about the incident that occurred on 3/17/2026, Staff D, RN stated: After dinner between 5:30 PM to 6:00 PM I was called to [Resident # 32's] room by Staff D, CNA and saw [Resident # 6] standing in the room. [Resident # 6] told me he was using the restroom. I informed the RN supervisor and was instructed to change [Resident # 6's] room to the 2nd floor and place [Resident # 6] on 1:1 monitoring. Record review of the facility's Policies and Procedures titled Policies and Procedures titled, Abuse, Neglect, Exploitation & Misappropriation Effective Date: 11/30/2014 Revision Date: 11/28/2017 revealed POLICY: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse.Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area. All types of sexual assault or battery, such as rape, sodomy and coerced nudity Forced observation of masturbation and/or pornography; and Taking sexually explicit photographs and/or audio/video recordings of a residents) and maintaining and/or distributing them (i.e. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident.Other examples of non-consensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious or is in a coma. Generally, sexual contact is non-consensual if the resident either: Appears to want contact to occur but lacks the cognitive ability to consent; or does not want contact to occur.

Based on observations, record reviews, and interviews, the facility failed maintain an environment free from accidents and hazards in potentially hazardous or unsafe areas on all three floors where residents resided. Observations included unlocked doors leading to soiled utility and biohazard rooms, laundry chutes, janitor closets, and the clean utility room containing stored oxygen tanks, which posed significant risks to residents' safety. At the time of the survey, 112 residents lived in the facility. The findings include.Observations on 03/23/2026, at 12:06 PM and on 03/24/2026, at 9:32 AM revealed the laundry chute on the third floor was unlocked. (Photographic evidence) Observation on 03/23/2026, at 12:19 PM revealed the third-floor janitors' closet door was unlocked. (Photographic evidence) Observations on 03/23/2026, at 12:27 PM and on 03/24/2026 at 9:14 AM the door third-floor clean utility room that stored the oxygen tanks was unlocked. (Photographic evidence) Observations on 03/23/2026, at 12:32 PM and on 03/24/2026 at 9:14 AM revealed the third-floor soiled utility room was unlocked. (Photographic evidence) On 03/25/2026, at 9:00 AM, the Director of Nursing (DON) explained in an interview that staff were required to keep the laundry chute and soiled utility rooms locked. The DON also noted she did not know whether a resident could inadvertently become locked inside the laundry chute room. She clarified that maintenance had replaced the keypads, especially in the janitors' closets because the doors were being left open. Interview on 03/26/2026 at 9:21 AM, the Director of Environmental Services revealed he changed the locks for the laundry chute on the third and second floors and replaced and installed keypads and combination locks on some doors that did not have keys. Observation on 03/23/2026 at 10:39 AM revealed Staff F from Housekeeping exited the janitor's closet on the second floor without locking the door. (Photographic evidence) On 03/23/2026, at 10:47 AM, the Director of Nursing was informed of the identified concern and remarked: The room should be locked because it contains hazardous materials. Subsequently, the Director of Nursing and the surveyor inspected the janitor's closet, confirming that the room contained hazardous materials. (photographic evidence) On 03/23/2026, at 10:39 AM, Staff F from Housekeeping was interviewed regarding the facility's protocol for the janitor's closet. Staff F stated, I am supposed to keep the door locked. On 03/24/2026 at 9:54 AM The Maintenance Director reported: I changed the lock to a code key to prevent the door from being kept open. Observation on 03/25/2026, at 10:33 AM, revealed the biohazard room located on the second floor was not secured. The Wound Care Registered Nurse was able to open the door without entering a keypad code to dispose of the red biohazard bag from wound care. (Photographic evidence) Interview on 03/25/2026 at 11:19 AM Staff C, Wound Care Registered Nurse stated I also noticed that the biohazard room was unlocked and it should always be locked to prevent residents from accessing it. I usually have to enter a code to get in, but it was already open this time. Record review of the facility's Policies and Procedures titled Chemical Storage Revision Date: 08/2025 revealed: Policy: Chemicals and hazardous materials shall be stored and handled in a manner to minimize the risk of injury to staff and residents or property damage. Procedure: Store and dispense chemicals/hazardous materials from originally marked containers or specifically label /marked dispensers. The facility shall have available and maintain SDS's (safety data sheets) for chemicals used or stored Staff are to be trained upon hire and annually on handling and storage of chemicals/hazardous materials. Chemical storage rooms and /or chemical storage cabinets are to be locked when not in direct site of a staff member. Store full and partially empty containers in locked areas per the Life Safety Code and OSHA requirements. Dispose of empty containers in accordance with SDS.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to demonstrate effective plans of action were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F689 Free of Accident Hazards and Supervision and Devices, F761 Label and Store Drugs and Biologicals, F880 Infection Prevention and Control and F919 Resident Call System. These repeated deficiencies had the potential to affect 112 residents residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 09/13/2024, F689 Free of Accident Hazards and Supervision and Devices was cited related to the facility failed to ensure the facility remained free from accident hazards as evidenced by not providing direct supervision for 1 of 23 residents who smoke and excess lint in 1 of 2 dryers in the laundry room. F761 Label and Store Drugs and Biologicals was cited related to unsecured medications at bedside and wound treatment carts. F880 Infection Prevention and Control was cited related to rodent control, blood glucose monitoring, wound care, and maintaining separation between the soiled linen area and the clean laundry area. F919 Resident Call System was cited related nonfunctioning of the residents' call systems in room and bathrooms. During this survey with exit dated 03/26/2026 the facility was cited F689 Free of Accident Hazards and Supervision and Devices, F761 Label and Store Drugs and Biologicals, F880 Infection Prevention and Control and F919 Resident Call System. Interview with the Administrator on 04/05/2026 at 5:51 PM revealed the (QAPI) Quality Assurance and Performance Improvement (QAPI) meetings are held once per month and as needed. The last meeting was held on 02/25/2026, and a stabilization meeting was held on 03/12/2026. The Quality Assessment and Assurance (QAA) committee required members, including Administrator, Director of Nursing (DON), Assistant Director of Nursing, Medical Director, Admissions, Social Services, Minimum Data Set (MDS), Activities, Dietary, Infection Preventionist, Therapy, Maintenance, and Business Office. The purpose of the QAA committee is to review and discuss the overall operations of the facility, identify areas where improvement may be needed, discuss potential solutions, and develop plans to address those areas in order to enhance outcomes and maintain standards of care. The QAA committee becomes aware of issues through reports presented by each department, staff reporting, clipboards at nursing stations, communication among department heads, and concerns identified during daily rounds. Issues that could endanger residents are addressed immediately and less urgent concerns are scheduled for later review and follow-up. Record review of Quality Assurance Performance Improvement (QAPI) policy revealed the Center has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. The center's QAPI program is an on-going comprehensive review of care and services provided to residents, including medical care, clinical care, rehabilitation, pharmacy services, dining services, social service, community life services, hospitality services, environmental services, admissions, business office, and medical records, as well as continuity of care, infection control, plant technology and safety management, information management, human resources, leadership and credentialing, resident/family education, and allegations of abuse, neglect, misappropriation of resident property. Review of activities may include infection control, incident/accident reports, resident/family complaints/satisfaction, interdisciplinary care planning, medication use, environment of care/safety, restraint reduction, wound care/prevention, staff orientation, in-service and competence, weight program, psychotropic drug reduction, fall prevention, medication error, and physician services. The program is a coordinated effort among departments and services within the organization and involves leadership working with input from center staff, residents and families. The center will obtain feedback to assist in identifying problems and areas of opportunity and will collect and monitor data from different departments reflecting their performance. The center will establish performance indicators, utilize performance indicators to establish goals, identify opportunities for improvement, evaluate progress towards goals, and ensure systems and actions are in place to improve performance. The center will establish and utilize a systematic approach to identify underlying causes of problems, develop and monitor action plans, and review and develop corrective actions on medical errors and adverse events. The center will monitor department performance systems to identify issues or adverse events and oversee the development of corrective actions. The center utilizes performance improvement projects to improve a systemic problem or improve quality, and at a minimum must conduct one performance improvement project annually.

Based on observations, records reviewed and interviews, the facility did not protect residents' information on one of four medication carts (West side cart) and one of two vital signs machines. Staff left an unattended computer screen on the west side medication cart and a vital signs machine open and unattended on the second floor, both displaying residents' information. At the time of the survey, 112 residents lived in the facility. The findings included: Observation on 03/23/2026 at 9:49 AM on the third floor revealed the computer screen was left open on the unattended west side medication cart displaying residents' information. (photo evidence).On 03/23/2026 at 10:00 AM Staff D, Registered Nurse (RN) was asked about the unattended west side cart's open computer screen with residents' information displayed. Staff D, RN stated: I am supposed to close the computer screen by hitting the icon to protect residents' information. The reason I left it open was because I was helping a resident.During an interview on 03/23/2026 at 10:45 AM the Director of Nursing (DON) stated: Staff are to lock the computer screens by turning them off or pressing the hide button to protect residents' information. On 03/24/2026 at 8:47 AM observation on the facility's second floor revealed an unattended vital signs machine screen was left open with residents' information visible.On 03/24/2026 at 8:50 AM Staff E, Registered Nurse (RN) was made aware of the unattended vital signs machine screen was left open; Staff E, RN stated, It should be closed.On 03/24/2026 at 8:56 AM, the Assistant Director of Nursing was interviewed about the facility's protocol for protecting residents' information and stated, Staff are to close the vitals machine once finished because it displays residents' information.` Record review of the facility's Policies and Procedures titled Confidentiality of Records Effective Date: 5/29/2023 revealed: Policy: The facility will protect/safeguard the residents' confidentiality.

Based on observations, record reviews, and interviews, the facility did not adhere to proper infection prevention and control protocols. Specifically, Staff C, a Wound Care Registered Nurse (RN), failed to perform hand hygiene during wound care procedures. At the time of the survey, there were 112 residents living in the facility. The findings include:Observation on 03/25/2026 at 10:33 AM of wound care performed by Staff C, Wound Care Registered Nurse (RN) for Resident # 62's stage 4 sacral wound; Staff C, Wound Care RN gathered required supplies to treat the resident's wound according to physician orders dated 03/20/2026 to cleanse sacral wound with saline, pat dry. Apply Honey impregnated. Cover with border dressing daily and as needed (PRN) in the morning for Wound Care and as needed for Wound Care . Staff C, Wound Care RN performed hand hygiene and gown and gloves were applied. The procedure was explained to the resident, and the old dressing dated 03/25/2026 was removed. Staff C, Wound Care RN removed gloves and applied new gloves before cleaning the wound with normal saline. Gloves were removed again and clean gloves were applied to dry the wound. Staff C, Wound Care RN then removed gloves and applied new gloves to place the honey dressing over the wound, followed by the silicone dressing, and dated the new dressing. After completing the procedure, Staff C, Wound Care RN removed gloves and applied clean gloves to discard the trash into the biohazard bag. The waste was taken to the biohazard room, which was noted to be unlocked. Staff C, Wound Care RN then removed gloves and used hand sanitizer after leaving biohazard room.Record review of a demographic sheet revealed Resident # 62 was admitted to the facility on [DATE] with diagnosis that included but not limited to: Pressure ulcer of sacral region, stage 4. Record review of the Quarterly Minimum Data Set (MDS) reference dated 03/05/2026 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no evidence of cognitive impairment, requiring substantial assistance for eating, toileting, showering, sit to lying and upper and lower body dressing. Impairment on both sides to the upper and lower extremities. Record review of Resident #62's skin integrity care plan revealed the resident is at risk for impaired skin integrity related to: Positioning preferences/tolerance increase risk, Impaired mobility and Incontinence.During an interview on 03/25/2026 at 11:19 AM with Staff C, Wound Care RN the infection control concerns were discussed and Staff C, Wound Care RN stated: I have been a wound care nurse at this facility for 2 years; I normally perform hand hygiene throughout the treatment, but I was a little nervous during this observation. I also noticed that the biohazard room should always be locked to prevent residents from accessing it. I usually have to enter a code to get in, but it was already open this time.Review of the facility's policy and procedure titled Infection Control Guidelines for All Nursing Procedures April 2013 stated 3. Employees must wash their hands for ten (10) to fifteen (15) seconds usingantimicrobial or non-antimicrobial soap and water under the following conditions:a. Before and after direct contact with residents.b. When hands are visibly dirty or soiled with blood or other body fluids.c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin:After removing gloves.d. After handling items potentially contaminated with blood, body fluids, or secretions.f. Before eating and after using a restroom; andg. When there is likely exposure to spores (i.e., C. difficile or Bacillus anthracis)(Note: Alcohol-based hand rubs are inactive against spores.For effectivemechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% chlorhexidine gluconate.)4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations:a. Before and after direct contact with residents.b. Before donning sterile gloves.c. Before performing any non-surgical invasive procedures:d. Before preparing or handling medications.e. Before handling clean or soiled dressings, gauze pads, etc.f. Before moving from a contaminated body site to a clean body site duringg. After contact with a resident's intact skin.h. After handling used dressings, contaminated equipment, etc.i. After contact with objects (e.g., medical equipment) in the immediate vicinity ofj. After removing gloves.

Based on observations records reviewed and interviews the facility failed to ensure a safe bathing environment for one resident (Resident #100) out of two sampled. Resident #100 sustained a cut on the bottom of his right foot in the shower from a protruding metal screw, which secured the metal grate drain cover. This deficient practice increased Resident #100's risk for serious chronic wound complications such as an infection. The findings included: During the Residents' Council meeting held on 03/25/2026 at 1:45 PM Resident #100 reported he sustained a cut on his foot in the shower.On 03/25/26 at 3:25 PM Resident #100 was observed in his room sitting in a chair the resident showed the surveyor an undated bandage on the bottom of his right foot and reported the cut was treated by a Staff I Registered Nurse (RN) on 03/24/2026. The resident removed the bandage and a cut measuring approximately 1.5 inches long with scant yellow drainage was noted.On 03/25/26 at 3:27 PM inspection of Resident #100's shared bathroom shower revealed visible mildew residue accumulated on the floor tiles, hair collected in the round metal grate drain cover and found one of the three metal screws securing the drain cover protruded and was not fastened properly. (Photographic Evidence) Record Review of Resident #100's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to Epilepsy, Transient Ischemic Attack (TIA) Major Depressive Disorder, Recurrent and Other Chronic Pain and Weakness. Review of the comprehensive Minimum Data Set submitted 02/20/2026 cognitive section revealed a Brief Interview of Metal Status score of 14 out of 15 indicating the resident is cognitively intact. The functional section revealed Resident #100 required set-up and clean up assistance for Activities of Daily Living.Record review of a Skin/Wound Note with effective date: 03/25/2026 timestamped 16:14 (4:14 PM) completed by Staff N, Licensed Practical Nurse note text indicated: Resident evaluated by wound care nurse for wound under right plantar. Treatment administered as standard order by wound care physician .Record review of progress notes completed by the Director of Nursing (DON) dated 3/25/2026 time stamped 17:40 (5:40 PM) Note Text: Resident reported that he sustained a cut to his foot approximately two days ago while in the shower. Resident stated he did not report the injury at the time. Resident further stated that a nurse later inquired about his limping. Wound care treatment was initiated, and the wound care nurse was notified MD (Medical Doctor was notified, and new order was received to transfer the resident to the hospital for further evaluation and treatment. Resident was educated on the importance of hospital evaluation, including potential risks of untreated wounds such as infection and delayed healing . Record review of physician order dated 03/25/2026 indicated standard order: Clean wound on right plantar foot with saline, pat dry. Apply Med honey to wound bed, Cover with boarder dressing gauze and PRN (as needed), in the morning for wound care and as needed. During an interview on 03/26/2026 2:24PM the Director of Maintenance/ Housekeeping and Laundry revealed he was informed on 3/25/2026 of a screw in Resident #100's shower posing a hazard and had received emails from the administration concerning the shower needing to be cleaned with picture attachments and further reported that Resident #100's shower was inspected on 3/8/2026 and 03/23/2026 and stated: I had not gotten around to getting the shower cleaned.Record review of the facility's Physical Environment - Room Repairs policy dated 09/26/2023 revealed, Maintenance Director or Designee will complete room rounds 2-4 time per month. Findings from these rounds will be prioritized and the repairs made as indicated. Apart from completing room rounds, a maintenance log is kept at the nurse's station for any repairs staff find need completed throughout the day. Staff will put maintenance request into the log; maintenance department will check log throughout the day to complete tasks. Any repairs requiring immediate attention are to be reported directly to the Maintenance Director or Administrator.Record review of facility complete room procedure included: 3.) Scrub bathroom floor (if ceramic tile) 4.) Complete 8-step room cleaning procedure (20-25 min)

Based on observations, record reviews and interviews the facility failed to store medications and biologics properly for one (Resident #84) out of seven sampled residents. Resident # 84 had an over-the-counter topical medication used to relieve oral pain a medicated lotion at bedside. There were 112 residents residing in the facility at the time of survey. The findings included:Observation on 03/23/2026 at 10:03 AM in Resident # 84's room revealed a container of [brand] over-the-counter topical medication used to temporarily relieve oral pain on the side table and a medicated lotion on the nightstand. (photo evidence). On 03/23/2026 at 10:19 AM Staff E, Registered Nurse (RN) was made aware of the identified concern and stated: Residents cannot have medications at the bedside without a physician's order. During an interview with the Director of Nursing (DON) on 03/23/2026 at 10:46 AM it was revealed that Resident #84 did not have physician's order to keep over-the-counter topical medication used to temporarily relieve oral pain or medicated lotions at the bedside. Record review of the facility's Policies and Procedures titled Subject: Medication Storage Effective Date: 12/08/2023 revealed Policy:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Procedure:1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.Only the issuing pharmacy is authorized to transfer medications between containers.2.The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.6.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.7.Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations records reviewed and interviews it was determined that the facility did not accurately complete Level I Preadmission Screening and Resident Review (PASRR) forms for two out of three sampled residents diagnosed with a Serious Mental Illness (SMI). Resident # 5's diagnosis of Schizophrenia was omitted on the Level I PASRR form despite being admitted to the facility with this diagnosis. 2. The Level I PASRR for Resident # 6 did not include documentation of exhibited behaviors posing potential risks to others. At the time of the survey, there were 112 residents residing in the facility. The findings included: Resident # 5On 03/23/2026 at 10:13 AM, the surveyor observed Resident #5 lying in bed with eyes closed.On 03/23/2026 at 11:45 AM, Resident #5 was observed walking in the hallway with a walker the surveyor greeted the resident, but Resident #5 did not respond.Record review of Resident #5's clinical records revealed an admission date of 5/9/2025 and readmission on [DATE] with diagnosis that included: Schizophrenia, Generalized Anxiety Disorder, Mood Disorder, and Psychosis. Record review of an admission Minimum Data Set (MDS) reference dated 5/16/2025 revealed Residet#5 was not considered by the State Level II Preadmission Screening and Resident Review (PASRR) process to have Serious Mental Illness and/or Intellectual Disability or a related condition diagnosis that included: Anxiety disorder and Psychotic disorder, received no Psychological Therapy. Further review of a Quarterly MDS reference dated 2/14/2026 revealed Resident #5 had diagnosis that included: Schizophrenia, Psychotic disorder, and Anxiety disorder, and was taking antipsychotic medications. Record review of a Care Plan started on 05/13/2025 revealed Resident # 5 had a behavior problem related to noncompliance with treatment regimen, refuses Activities of Daily Living (ADL) care, refuses labs, refuses medications, resists care, and Delusions with interventions that included: Notify Medical doctor for continuing of refusing medications, provide a program of activities that is of interest and accommodates residents status and Psych consult as ordered. Record review of Resident # 5's physician's order sheet revealed orders dated 2/12/2026 for Risperidone Oral Tablet 1 milligram (MG) directions: Give 1 tablet by mouth two times a day related to Schizophrenia.Review of Resident # 5's medical records revealed the resident was evaluated by a Psychiatrist on 2/10/26.Review of the most recent PASRR provided by the Director of Nursing (DON) dated 2/18/2026, Section I: PASRR Screen Decision- Making A. MI or suspected MI (check all that apply): Anxiety, Schizoaffective Disorder, Delusional Disorder, Mood Affective Disorder, Adjustment Disorder and Insomnia were checked. Schizophrenia was not checked. On 03/26/2026 at 1:45 PM, the DON stated, [Resident #5] was initially admitted on [DATE] with Schizophrenia diagnosis and hospitalized on [DATE] and returned on 2/9/2026. At the time of return the Psychiatrist did not include Schizophrenia in diagnosis list so I did not include in the PASRR. The diagnosis of Schizoaffective is not in the psychiatric notes and the PASRR is incorrect. Resident # 6Record review of a Federal Report revealed on 03/17/2026 at 6:07 PM, Staff G, CNA, reported to the Registered Nurse (RN) supervisor, that Resident # 6 was found in another resident's room, on top of the other resident with his clothes fully on and the other resident was not wearing a brief.On 03/23/2026 at 9:05 AM Resident # 6 was observed in room with a 1:1 monitor. On 03/24/2026 at 4:42 PM Resident #6 was observed in room with a 1:1 monitor at bedside. Resident #6 was interviewed and stated, I have helped female residents cover their breasts by adjusting their shirt.Record review of a demographic sheet for Resident # 6 revealed an admission date of 5/13/2025 with diagnosis that included: Paranoid Schizophrenia, Generalized Anxiety Disorder, and Other depressive episodes.Record review of Resident # 6's physicians order sheet revealed orders dated: 5/16/2025 for Remeron Oral Tablet 30 MG (Mirtazapine) directions: Give 1 tablet by mouth at bedtime for depression, 5/23/2025 for Haloperidol Oral Tablet 10 MG (Haloperidol) directions: Give 1 tablet by mouth at bedtime for psychosis, 6/24/2025 for Haloperidol Decanoate Solution 100 MG/ML directions: Inject 1 ml intramuscularly one time a day every 21 day(s) for Psychosis and 7/16/2025 for Klonopin Oral Tablet 1 MG (Clonazepam) *Controlled Drug* directions: Give 1 tablet by mouth three times a day for anxiety and labile behavior.Record review of an admission Minimum Data Set reference dated 5/20/2025 revealed Resident#6 was not considered by the State level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, had Anxiety disorder, Depression (other than bipolar), Psychotic disorder, was taking Antipsychotics and Antidepressants and received no Psychological TherapyRecord review of Psychiatric notes dated 3/18/2026, 2/10/2026 and 12/3/2025 indicated Resident # 6 had diagnosis of: Depression, Psychosis, Anxiety, and Paranoid Schizophrenia.Record review of a Care plan initiated on 05/13/2025 and revised on: 03/24/2026 revealed Resident#6 had behavior problem related to curses, noncompliance with treatment regimen, refuses labs, yells out, Mood swings, inappropriate sexual behaviors toward staff and other residents, refuses medications. Resident exhibits sexual inappropriate behavior toward another resident Related to paranoid schizophrenia, other specified depressive episodes, and psychotic disorder with delusions due to known physiological condition with interventions that included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet The resident's needs. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak CNA in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Provide 1:1 supervision as much as possible.On 03/25/2026 at 9:41 AM Resident #34 stated, [Resident #6] has exposed genitals to me once about a week ago. I did not report that to staff. I don't feel staff are observant enough.On 03/25/2026 at 10:10 AM Staff H, Certified nursing assistant (CNA) was interviewed outside of room and stated, I am the 1:1 monitor for [Resident # 6] today. [Resident # 6] exposed his genitals to me several times in the past with the last time being a month ago. I informed administration. On 03/25/2026 at 10:18 AM, the DON was made aware of identified concerns and revealed the facility was aware Resident # 6 had exhibited behaviors of exposing his genitals and masturbating in front of staff and other residents.Resident #6's most recent PASRR was requested and the Director of Nursing (DON) the PASRR provided for Resident #6 dated 9/4/2025, Section I: PASRR Screen Decision- Making A. MI or suspected MI: Check all that apply Anxiety, Psychotic, Schizophrenia Substance abuse was checked. Depression was not checked.During an interview about the facility's policy for completing a Level I PASSR on 03/25/2026 at 12:56 PM, the DON stated, We review the clinical information before filling out the PASRR. For [Resident # 6] Depression was not checked on the PASRR and should have been checked. Surveyor asked why a new PASRR had not been completed to include Resident # 6's recent behaviors towards other residents, and the DON replied, I will get back to you.On 03/25/2026 at 1:02 PM the DON stated, I completed a new PASRR today, to include the diagnosis of Depression and yes to the question has the individual exhibited actions or behaviors that may make them a danger to themselves, or others and a Level II is now required. Record review of the facility's Policies and Procedures titled, Preadmission Screening and Resident Review (PASRR) Effective Date: 11/08/2021 revealed Policy:The center will assure that all Serious Mentally III (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting.Procedure:It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical recordIf an individual is declared exempt from a PASRR screening, the Center should make sure that appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include:Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery.Those who are certified by a physician as to be terminally ill with a 6-month prognosis and are not a danger to self or others.Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's Disease, Huntington's Disease, Amyotrophic Lateral Sclerosis, CHF or COPD.d. Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis.There are no exceptions for Intellectually Disabled (ID) screenings.If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed.Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual.Social Services/designee will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records.

Based on observations, record reviews, and interviews, it was determined that the facility did not uphold the residents' right to adequate and appropriate health care for one (Resident #32) out of two sampled residents who returned to the facility after hospitalization with medication orders to continue post-discharge. Resident # 32 was transferred to the hospital after being sexually assaulted in the facility. The hospital's medical provider ordered and instructed the continuation of prophylactic medications for Resident # 32 upon discharge; however, the facility failed to implement this order. This omission increased Resident # 32's risk of an untreated sexually transmitted infection. At the time of the survey, 112 residents resided in the facility. The findings include: Record review of a Federal Report revealed on 03/17/2026 at 6:07 PM Resident # 32 was observed by facility staff in bed with Resident #6 on top of Resident # 32. At that time Resident # 32 was not wearing a brief. Further review of report revealed Resident # 32 was sent out to the hospital for a Rape Kit and Sexual Transmitted Disease test to be conducted as a precaution.On 03/23/2026 at 9:05 AM Resident # 32 was observed in her room, seated on the side of the bed and stated: I want bathroom. The call system was not working so the Surveyor notified a staff member that the resident needed assistance.On 03/25/2026 at 10:19 AM Resident # 32 was in bed with no apparent distress and voiced no concerns.Review of the hospital's summary report revealed Resident # 32 was admitted for medical clearance following a suspected sexual battery.Review of Resident #32's hospital flowsheets revealed orders for antibiotics Doxycycline 100 milligram (mg) twice a day and Metronidazole 500 mg tablet every 8 hours on 03/19/2026 as prophylaxis treatment.Review of Resident # 32's Hospital Discharge Needs and Care Plan; Post-Hospital Care Requirements revealed Resident #32 required ongoing monitoring and prophylaxis following the suspected assault alongside management of her chronic conditions. Post-Exposure Prophylaxis completion of the initiated medication regimen for infection prevention. Record review of nursing notes dated 03/20/2026 timestamped 7:00 PM revealed around 16:00 PM [Resident #32] was readmitted to Gardens Nursing and Rehabilitation. [Resident # 32]. Primary admitted diagnosis sexual assault of adult.Record review of Resident # 32's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included Alzheimer's Disease, Psychosis, Cerebral Infarction, Depressive episode and Mood [AFFECTIVE] Disorder.Review of Resident#32's electronic health records revealed a Physician's progress note dated 03/22/2026 that did not address the continuation of prophylaxis post exposure medication.Record review of the March 2026 physician's order sheet revealed Resident # 32 had no orders pertaining to prophylaxis medications.Record review of a Quarterly Minimum Data Set (MDS) reference dated 03/1/2026 revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment and was independent for toileting hygiene and transferring.During an interview on 03/25/2026 at 11:34 AM the Director of Nursing (DON) was asked about the facility's continuation of care for Resident #32 after hospitalization. The DON stated: We refer to the discharge list. I noticed the resident was receiving prophylaxis in the hospital, but we did not carry those orders over. I can call the doctor now to see what prophylaxis medications are to be ordered for [Resident # 32]. The DON then returned at 11:35 AM and reported the physician was called and lab work for the other resident involved in the sexual assault was ordered.Record review of the facility's Policies and Procedures titled, Medical Care-Standards of Practice/Physician Services Effective Date: 12/01/2024 revealed Policy:Residents will be admitted under the care of a physician of his/her choice provided the physician adheres to applicable federal, state, and local regulations along with Center policy and procedures. The physician will be licensed by the appropriate state Board of Medicine and will adhere to the Standards of Practice.Procedure:6. The assigned physician is responsible for verifying the history and physical information is relevant and /or adds additional information as needed to reflect the current status of the resident. This is to include but not limited to: A new H & P annually, at a minimum.A revision of the existing H & P that is 12 months old ONLY when the revision is considered minor and there has been no significant change in the residents' condition.

Based on observations, record reviews and interviews it was determined that the facility failed to honor one (Resident # 92) of two sampled residents' rights to be free from restraints. On two separate occasions, it was noted that the left side of Resident # 92's bed was positioned against the wall, which restricted Resident # 92's ability to exit the bed safely. At the time of the survey 112 residents were residing in the facilityThe findings include:Observation on 03/23/2026 at 9:58 AM revealed Resident # 92 had bilateral side rails up and the left side of the bed against wall. Photo evidence provided. Observation on 03/25/2026 at 9:20 AM revealed Resident # 92 had bilateral side rails up and the left side of the bed was positioned against wall. Photo evidence provided. Record review of a demographic sheet revealed Resident #92 was admitted to the facility on [DATE] with diagnosis that included but not limited to: metabolic encephalopathy and transient alteration of awareness.Record review of the admission Minimum Data Set (MDS) reference dated 02/19/26 revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment. The resident required substantial assistance for eating, toileting, showering, sit to lying and upper and lower body dressing and had impairment on both sides to the upper and lower extremities. Record review of Resident # 92's Activities of Daily Living (ADLs) care plan revealed self-care performance deficit related to (r/t) Weakness, Encephalopathy, Fatigue, Chronic disease burden, Hospital deconditioning, Cognitive fluctuation. Evidence: Total self-care deficit listed, Altered mental status (AMS) and Functional decline. Interventions include: The resident is totally dependent on (1-2) staff for repositioning and turning in bed, the resident is totally dependent on (1) staff for personal hygiene and oral care and the resident requires mechanical lift with (2) staff assistance for transfers. Interview on 03/25/2026 at 9:24 AM with Staff A, Registered Nurse (RN) stated I did not place the bed against the wall because it should remain in the middle to allow safe access from both sides. Placing the bed against the wall is considered a restraint and is not permitted. The resident is confused and frequently attempts to get out of bed. The physician explained that this confusion is due to elevated ammonia levels, and the resident's lactulose has been increased to help manage this condition. I have also observed that the resident attempts to pull down the Percutaneous Endoscopic Gastrostomy (PEG) feeding pole, which increases his risk for injury and could interfere with his treatment. Interview on 03/25/2026 at 9:53 AM with Staff B, Certified Nursing Assistant (CNA) stated I did not put the bed against the wall. I do not know how it was moved or if the resident tried to get out of bed.During an interview on 03/25/2026 at 09:57 AM, the Director of Nursing (DON) stated I will educate the staff not to place the bed against the wall, as it is considered a restraint. I was not aware that this resident is confused or attempts to get out of bed. Review of the facility's policy and procedure titled Resident Rights dated 10/18/2018 documented:Policy: It is the policy of the company to:1. Make residents and their legal representatives aware of residents' rights.2. Ensure that residents' rights are known to staff.3. Ensure residents' rights are honored.

Based on observation, interview and record review, the facility failed to store food under sanitary condition in two out of two snack/nourishment refrigerator on the resident's unit. as evidenced by residents' foods brought to the facility by visitors and family were observed unlabeled and not appropriately dated. This deficient practice has the potential to affect residents receiving food brought in from outside sources. The findings include.Observation on 06/25/2025 at 3:15 PM of the facility's Nourishment Pantries refrigerators that stores resident's food that is brought into the facility by visitors, family and other outside sources revealed the refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names. The third-floor refrigerator also had several unlabeled undated plastic bags with food items. Interview on 06/25/2025 at 3: 25 PM Interview with Staff J, Registered Nurse revealed (RN) stated: all these foods belong to the residents. items in the refrigerator located in the pantry to residents. Interview on at 3:45 PM, the Assistant Director of Nursing acknowledged the concerns and revealed: Food should be labelled and dated with the resident's name and should be discarded after three days. Review of the facility's policy titled: Foods Brought in By Family and Visitors indicate:POLICY:It is the policy of this facility to permit liberalized diets as much as possible. Staff must be aware of foods brought to a resident by family/visitors.PROCEDURE:1. Family members/visitors must inform the nursing staff of their desire to bring foods into the facility.5. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator (used for resident items). Containers must be labeled with the resident's name, the item and the use by date.6. The facility staff, in charge of cleaning the common area refrigerator, is responsible for discarding perishable foods on or before the use by date/3days. The family is responsible for discarding perishable food stored in personal refrigerators kept in resident rooms.

Based on record reviews and interviews facility failed to notify one (Resident #1) out of three sampled residents' representative of a change in condition. As evidenced by Resident #1 with a clinical diagnosis of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) left the facility Against Medical Advise (AMA) and the responsible party was not notified.The findings included:Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] with diagnosis that included: Schizophrenia and Psychosis, responsible party listed: [] Advocacy Group and discharged on 5/5/2025.Record review of an admission/discharge/transfer list revealed Resident#1 was listed as discharged Against Medical Advice on 5/5/25.Record review of an admission Minimum Data Set (MDS) reference dated 3/24/2025 revealed Resident#1 had a Brief Interview of Mental Status score of 14 out of 15; indicated no cognitive impairment, was taking Antipsychotic medications and did not have a wander/elopement alarm and had an active discharge planning occurring for return to the community.Interview on 06/25/2025 at 3:50 PM via telephone, Resident #1's Advocate/Representative stated: The last time I saw [Resident #1] was in the hospital on [DATE], I was not notified [Resident #1] is not at the facility, it is not safe for him to be out he need his medication.Record review of Resident #1's physician's order sheet for May 2025 revealed orders dated 3/17/2025 for Olanzapine oral tablet 5 Milligram (MG) by mouth at bedtime for Psychosis, order dated 3/18/2025 Monitor blood sugar every shift, Colostomy Care Every Shift every shift and monitor/document for behaviors, and order dated 3/25/2025 Olanzapine Oral Tablet 10 MG give one tablet by mouth at bedtime for Psychosis.Record review revealed Resident #1 had a care plan initiated on 3/18/2025 and revised on: 05/08/2025 for Alteration in mood and/or behavioral status AEB/ Related to: Psychotic symptoms (Hallucinations/Delusions) with a goal to be easily redirected and free from injury/adverse outcome related to wandering through next review and interventions that included: Monitor resident for ongoing psychosocial issues. Record review of a progress note dated: 5/5/2025 at 11:10 AM revealed Resident #1 left AMA and form was not signed. On 6/26/25 at 9:00 AM, the DON (Director of Nursing) stated: A Night shift staff called me around 11:00 PM on 5/4/25 and reported to me that the CNA (Certified Nursing Assistant) could not find the resident (Resident #1). I instructed them to look everywhere and that I would be in my way. I notified the administrator. They called me back and said they found the resident in another resident's room, and the resident was determined to leave. I instructed the supervisor to stay with the resident. The next morning when I came in, I spoke with [Resident #1], and the resident insisted on leaving. At that time, I checked and saw [Resident#1's] BIMS score was 14. I then spoke to the medical doctor and the doctor advised to let [Resident #1] leave AMA. I presented the AMA form to [Resident #1] and the resident refused to sign it. I called the responsible party three or four times, left a voicemail and no response was received.During an interview on 6/26/25 at 9:42 AM, the Social Services Director (SSD) stated: If a resident left AMA. I normally do a wellness check if I have the discharge location, however for [Resident #1] I did not have a location. The health care proxy is to be notified about any incident, and they are the person who is to sign a resident out AMA. The Social Services Director presented Resident #1's signed Affidavit of Health Care Proxy dated 3/3/25 indicating Patient name: [Resdient#1], Agency accepting Proxy Designation:Record review of a Policy titled Against Medical Advice effective date 05/10/2024 indicated:Procedure:5. Notify the resident's representative, family, or designated person that the resident is leaving the facility AMA and document in the medical record.

Based on observation, record review and interviews the facility failed to ensure one (Resident #1 out of three (Resident #1) safely and appropriately discharged to a safe location where ongoing clinical care could be provided, as evidence by on 05/05/2025 Resident #1 a vulnerable resident with clinical diagnoses of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) insisted on leaving the facility was presented with an Against Medical Advise (AMA) form which he refused to sign. The facility did not obtain a valid address for Resident #1's next place of residence and did not inform the resident's advocate/representative about the AMA discharge. At the time of this survey Resident #1's location is unknown. The findings include: Observational tour of the facility's exterior revealed the facility is in a residential area with high volume of traffic and cross streets; the facility is not gated at the entrance. The facility has side fences (approximately four feet at the front of the building's parking lot and to the right while entering the facility the fence is approximately six feet extending to the rear of the facility of the building. The front entrance to the building requires a code to enter and exit. Tour of the facility's interior revealed only one out of two elevators in working condition and required a code to get on and off. The stairway has an alarm with a 5-10 seconds delay before the door is opened. Every exit door has an alarm. The patios on the second and third floor are screened but a resident could easily lift the screen and jump off the patio.Review of Resident #1's closed medical records revealed the resident was admitted to the facility on [DATE] and discharged AMA on 05/05/2025. Clinical diagnoses include Colostomy status, disorganized schizophrenia, other psychotic disorder not due to a substance or known physiological condition .Review of the Physicians Orders Sheet (POS) for May 2025 included an order dated 3/17/2025 for Olanzapine Oral Tablet 10 milligrams; give 1 tablet by mouth at bedtime for Psychosis Colostomy care every shift.Record review indicated Resident #1's Care Plans Initiated: 03/18/2025, Revision on: 05/08/2025 documented: Focus area: Alteration in mood and/or behavioral status related to psychotic symptoms (Hallucinations/Delusions). Goal: Will be easily redirected and free from injury/adverse outcome related to wandering through next review. Interventions: Provide additional Social Service support as needed. Offer/provide psychosocial support services as available/accepted. Medications as ordered, Redirect patient as necessary. 15 minutes checks per facility protocol. Monitor resident ongoing psychosocial issues . Care Plan Date Initiated: 03/19/2025 Revision dated 05/08/2025-Focus: Resident wishes to stay in the facility for Long Term Care. Resident discharged AMA, forms not signed. Goal: -Resident will have no psychosocial issues regarding the decision to stay in facility for LTC. Interventions: - Monitor resident ongoing psychosocial issues. Psych consultation as necessary Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 1 is cognitively intact. [NAME]- Adequate, Speech Clarity- clear speech, Makes Self Understood- usually understood/ understands . High-Risk Drug Classes taking: Antipsychotic; No wander/elopement alarm used; Active discharge planning already occurring for the resident to return to the community-YesReview of Progress Note dated 5/5/2025 02:19 (2:19 AM)-Narrative Nurses note: Resident left AMA form was not signed.Review of a Progress Noted dated 5/5/2025 2:44 AM: During the routine checkup, Staff notice [Resident #1] was not in his room. The Supervisor, primary nurse and staff searched the whole building but couldn't find the resident. The Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) were contacted. One of the residents shared [Resident #1] wanting to leave, and said he was tired of being locked up. MD (Medical Doctor) has also been notified. Tried reaching out to [] Florida Advocacy Group.but there was no response. Voicemail message was left for them to return the call . Interview on 06/25/2025 at 1:57 PM, the Director of Nursing (DON) revealed Resident # 1 went missing on the 3:00 PM to 11:00 PM shift and apparently the 11:00 PM to 7:00 PM shift staff reported the resident was found in another resident's room on the third floor. Interview on 06/25/2025 at 3:50 PM via telephone, Resident #1's Advocate stated: The last time I saw [Resident #1] was in the hospital on [DATE], I was not notified [Resident #1] is not at the facility, it is not safe for him to be out he need his medication. Interview on 06/26/2025 at 9:07 AM The DON) revealed: If a resident wants to leave AMA the staff are to notify me and either myself or staff try to convince the resident to remain in the facility. If the resident insists on leaving, the medical doctor is notified, and the resident is asked to sign a form that explains the risks. If a resident leaves AMA, we notify the MD (Medical Doctor) [local community-based State agency] and emergency contact. The most recent AMA was [Resident#1]. A night shift staff called me around 11:00 PM on 5/4/2025 and reported to me that the CNA (Certified Nursing Assistant) could not find the resident. I instructed them to look everywhere and that I would be in my way. I notified the administrator. They called me back and said they found the resident in another resident's room, and he was determined to leave. I instructed the supervisor to stay with the resident. The next morning when I came in, I spoke with [Resident #1] and the resident insisted on leaving. At that time, I checked and saw Resdient#1's BIMS (Brief Interview of Mental Status) score was 14 (score of 14 out of 15 indicate the resident is cognitively intact). I then spoke to the medical doctor and the doctor advised to let Resident #1 leave AMA. I presented the AMA form to Resident #1 and the resident refused to sign it. I did not write a progress note that the resident was here on 5/5/25 in the morning. I called three or four times to the responsible party and left a voicemail and no response. This resident has a diagnosis of Schizophrenia. During an interview on 6/26/25 at 9:42 AM, the Social Services Director (SSD) stated: If a resident left AMA. I normally do a wellness check if I have the discharge location, however for [Resident #1] I did not have a location. The health care proxy is to be notified about any incident, and they are the person who is to sign a resident out AMA. The Social Services Director presented Resident #1's signed Affidavit of Health Care Proxy dated 3/3/25 indicating Patient name: [Resdient#1], Agency accepting Proxy Designation: [Advocacy Group]. If a resident wants to leave AMA and I am present I request that they sign an AMA and advise them of the possible risks associated with leaving AMA. I don't remember if I told DCF that Resident #1 left AMA because I only forwarded the note written on 5/5/25 at 2:00 AM. On 6/26/25 at 10:50 AM The DON stated: I didn't document that the resident was found because there was a lot going on .No one called the police because the resident was found in another room.Interview on 6/26/2025 at 11:34 AM the DON reported that on 05/05/2025 Resident #1 insisted he wanted to leave and was presented with an Against Medical Advise (AMA) form, but he did not sign the AMA form and left the facility at 10:42 AM with his clothes and colostomy supplies. He was wearing shorts; we watched him cross the street to the bus stop. The Administrator (NHA) Minimum Data Set (MDS) Coordinator, Therapy Director and the Receptionist were present when the resident left. The DON revealed she was aware Resident #1 had an Advocate/Representative, and she called and left a message. The Doctor was also notified that the resident left AMA. The DON was asked why the facility did not [NAME] Act the resident for his own safety; the DON reported there was no Doctor's order to [NAME] Act the resident.Interview on 06/26/2025 at 2:10 PM with Staff C, Certified Nursing Assistant, revealed I have worked with [Resident #1] before and everybody work together with him, I remember that Sunday night about 10:00 PM they said he was missing, and we looked for him everywhere. I was leaving at 11:00 PM and they had not found him but the next day I heard that they had found him, and he had left. On 06/26/2025 at 2:18 PM, interview via phone with the Primary Care Physician (PCP) he stated: [Resident #1] was my patient; he was oriented and is independent. I received a call on Sunday 05/04/25 at around 11:00 PM stating [Resident #1] was missing. I did not hear from them until Monday morning and at that time they did not tell me where he was found that morning. They said he left AMA. The PCP was asked if it was safe for the resident to be out of the facility off his medication, The PCP stated, If the [Resident #1] does not get his medication, he will get worse. We got him from another county pretty much while he was at the facility he was ok; he needs his medication and needed to continue taking it because he was stable. I was not aware he was with the advocate program. When this kind of patient try to leave, he should be [NAME] Acted. The PCP was asked if a Physician's Order is required for a [NAME] Act, the PCP stated no, the facility have the right to call 911 because maybe at that time when he wanted to leave, he was experiencing or was in altered mental status. We have had patients that try to leave, and it is hard to escape from that facility. I was not notified until Monday morning and that was after he had already left AMA. Interview on 06/26/2025 at 2:35 PM, the Administrator (NHA) was asked about the incident related to Resident # 1 leaving the facility; the NHA stated: He left AMA, he did not tell us where he was going, it is not uncommon for homeless people to want to leave so he may have gone back to the streets, the doctor was called per the DON. The NHA was asked if she contacted the Advocate/ Representative, she stated: I left a message I only have a phone number. He usually makes his decision; he signed his admission package when he came in., we did not do a wellness check because according to Social Services Director (SSD), she reported it to [local community-based State agency], but they did not take the case. No police report or missing person reports were done because he left AMA. When asked if the resident can survive without meds, the NHA stated: Yes, he may have psychotic episodes, but he lived on the streets before he has no income .and when he needs supplies he will go to the hospital .He can change the colostomy bag himself. The staff reported he was missing at nighttime on the 11:00 PM to 7:00 AM shift and they found him in another resident's room (room number unknown). He said the next morning I can't be here. The NHA was asked if the resident's doctors were notified; the NHA stated: The primary doctor was called and I do not know if the Psychiatrist was called The NHA was asked if she thought a resident would be safe on the streets, she responded yes. He refused to sign the AMA. I witnessed him leaving. The NHA was asked if the Social Services Director (SSD) was made aware that the resident wanted to leave and, the NHA revealed the SSD was not involved. Follow up interview on 06/26/2025 at 3:38 PM, the SSD was asked if she had tried to encourage the resident not to leave the facility. The SSD stated: I was not involved and was not notified until after the resident ha left. The SSD further revealed: [Resident #1] expressed at times that he wanted to leave but not aggressively and was redirected. If I knew what was happening, I could have redirected him. I was at the facility that Monday he was not here when I put my note in; it is a concern that he is out there on his own . Interview on 6/27/25 at 9:50 AM, Staff G, Registered Nurse (RN) stated I am familiar with [Resident #1]. I have been his nurse several times. He was very quiet and short with words and always walking around. He never expressed any desire to leave the facility. He always took his medicine. I was told that this resident eloped. I would not consider that a safe discharge due to his Schizophrenia. Review of a Psychiatric Note for Resident #1 dated 3/24/2025 indicated: Resident #1 is very delusional, says the government has given him authority to take as much ecstasy as he wants and his family was executed, Diagnosis: Psychotic disorder .Schizophrenic disorganized type, recommendation to increase Olanzapine to 10 mg at bedtime.Interview via telephone on 06/27/2025 at 12:39 PM with the Psychiatrist, he stated: I know that resident he was new, but he is Schizophrenic and with those types of patients moods will change without warning; he needs to take his medication to remain stable; and if he left without saying where he is going that is dangerous because; He may be roaming around the streets and will get in trouble and the police will lock him up and maybe put him in a psych unit. I was informed a week ago that he was not in the facility. The facility should have tried to find out where he was and where exactly he was going. The expectation is for the facility to notify me immediately before they let him leave. the plan when he was admitted was for him to stay in the facility. The facility should have a protocol in place for a psychotic patient like [Resident #1]. This is a major concern because I was only told that he was not in the facility a week ago. On 6/27/25 at 1:50 PM with Staff I, Licensed Practical Nurse (LPN) that was assigned to Resident #1 on the date of the incident stated: I don't remember that resident [Resident #1]. I don't remember any resident going missing on my shift. I don't remember, I don't know that resident. When asked if she recalled residents on any of her assignment with colostomy she stated: I don't remember. Staff I was asked about the medication that was not administered nor signed off on the Medication Administration Records (MAR) on 05/04/2025, Staff I, again stated: I don't remember why I didn't sign the MAR. Review of the facility's policy provided titled Against Medical Advice, Effective date: 05/10/2024. Policy: A physician's order should be obtained for all discharges unless a resident or representative is discharging himself or herself against medical advice.Procedure: 1. Should a resident, or his or her representative request an immediate discharge; notify the physician and document in the medical record.2. If the resident or representative insists upon being discharged without the approval of the physician, the resident and/or representative should sign a Release of Responsibility (AMA) form. Should either party refuse to sign the release, such refusal is to be documented in the medical record. 5. Notify the residents' representative, family, or designated person the resident is leaving the facility AMA and document in the medical record.

Based on observation, interview and record review, the facility failed to honor their policy for Foods brought in by family/visitors for one (Resident #13) out of three sampled residents as evidenced by the facility's staff refuse to warm Resident #13's food brought in by family. The findings included: During observation on 06/25/25 at 12:55 PM Resident #13 was observed seated in her wheelchair at the bedside. Resident #13 revealed she had a recent disagreement with the dietary manager about her food that had been brought in by her brother being too burnt when staff warmed it up in the kitchen .As a result the Dietary Manager is unwilling to warm her food in the kitchen. The resident further explained the microwaves were removed and residents must warm up outside food in the kitchen. Interview on 06/25/25 at 02:25 PM, the Dietary Manager reported there is currently no microwave on each floor, as the previous ones were removed due to repeated damage and have not been replaced. Per facility policy, staff are not permitted to reheat outside food brought in by residents or their families. Only food prepared in-house may be reheated. This policy has been longstanding, though there have been numerous complaints from residents regarding the inability to warm up outside food. Review of the facility's undated policy titled: Foods brought in by family/visitors. POLICY: It is the policy of this facility to permit liberalized diets as much as possible. Staff must be aware of foods brought to a resident by family/visitors. PROCEDURE: 10. Outside food/liquids is only permitted to be reheated by dietary staff to prevent the possibility of bums or injury.

Based on observations, record review and interviews, the facility failed to develop and implement a discharge care plan for one (Resident # 1) out of three resident whose discharge care plans were reviewed. There were 106 residents residing in the facility at the time of this survey. The findings included: Record review of Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Clinical diagnoses include Displaced Tri malleolar Fracture of Right Lower Leg, Subsequent Encounter for Closed Fracture with Routine Healing, Encounter for Other Orthopedic Aftercare. Record review of orders dated 03/07/2025 indicated the resident was to be discharged home with family on 08/08/2025. Review of the Admission Minimum Date Set (MDS) Section C for Cognitive Patterns dated 02/11/2025 revealed the Brief Interview of Mental Status (BIMS) summary score was 07 out of 15 indicating severe cognitive impairment. The section for Functional Abilities dated 02/11/2025 revealed the resident was independent for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene. The resident needed partial/moderate assistance for shower/bath and lower body dressing and needed substantial/maximal assistance for putting on/taking off footwear. Record review of the overall Discharge Summary revealed the resident is to be discharged home with family. No medical equipment needed, or home health requested. The resident choice to be discharged on [DATE]. Review of the Admission Baseline Care Plan dated 02/06/2025 indicated on the Initial Admission/Discharge: Remain in the facility. Review of the MDS Discharge Return Non-Anticipated Information dated 03/08/2025 revealed the resident was discharged to home/community. Review of the Nursing Home Transfer and Discharge Notice dated 03/07/20205 revealed the facility gave the resident a 30-day notice to vacate the facility due to the resident's unpaid bill for services received at the facility after reasonable and appropriate notice to pay Based on observations, record review and interviews, the facility failed to develop and implement a discharge care plan for one (Resident # 1) out of three resident whose discharge care plans were reviewed. There were 106 residents residing in the facility at the time of this survey. The findings included: Record review of Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Clinical diagnoses include Displaced Tri malleolar Fracture of Right Lower Leg, Subsequent Encounter for Closed Fracture with Routine Healing, Encounter for Other Orthopedic Aftercare. Record review of orders dated 03/07/2025 indicated the resident was to be discharged home with family on 08/08/2025. Review of the Admission Minimum Date Set (MDS) Section C for Cognitive Patterns dated 02/11/2025 revealed the Brief Interview of Mental Status (BIMS) summary score was 07 out of 15 indicating severe cognitive impairment. The section for Functional Abilities dated 02/11/2025 revealed the resident was independent for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene. The resident needed partial/moderate assistance for shower/bath and lower body dressing and needed substantial/maximal assistance for putting on/taking off footwear. Record review of the overall Discharge Summary revealed the resident is to be discharged home with family. No medical equipment needed, or home health requested. The resident choice to be discharged on [DATE]. Review of the Admission Baseline Care Plan dated 02/06/2025 indicated on the Initial Admission/Discharge: Remain in the facility. Review of the MDS Discharge Return Non-Anticipated Information dated 03/08/2025 revealed the resident was discharged to home/community. Review of the Nursing Home Transfer and Discharge Notice dated 03/07/20205 revealed the facility gave the resident a 30-day notice to vacate the facility due to the resident's unpaid bill for services received at the facility after being given reasonable and appropriate notice to pay. Interview on 03/25/2025 at 1:35 PM the Social Services Director revealed she is not in charge of the development of care plans, and she is in charge of the Nursing Home Transfer and Discharge Notice. Interview on 03/25/2025 at 1:50 PM; the MDS Coordinator revealed she is in charge of the development of care plans. The MDS Coordinator acknowledge the resident did not have any discharge care plan. Record review of the facility's Policies and Procedures for Care Plan-Comprehensive with effective date 09/01/2022 revealed Overview: An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy: Our facility's care plan planning/Interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Procedure: 5- The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment.

Based on observations records reviewed and interviews; the facility failed to ensure Drug Regimen Reviews were completed for one (Resident # 13) out of three residents reviewed as evidenced by Resident #13 who was admitted to the facility has been receiving a combination of antidepressant, blood pressure medication, muscle relaxer, and atypical antipsychotic medication that has the potential to cause serious interactions and side effects has not received the Drug Regimen Review within the required time frame. The findings include. On 03/25/2025 at 10:15 AM Resident # 13 was observed smoking at the designated smoking patio located on the second floor interacting with staff. On 03/26/2025 at 11:19 AM Resident #13 was observed in the elevator going up to the third floor. It was noted that another resident made fat shaming remarks directed at Resident #13. Who did not respond and held her head down. On 3/27/2025 at 9:35 AM Resident # 13 was observed on the smoking patio and interacted with staff. On 3/27/2025 at 9:50 AM Resident #13 was in her room, and was compliant with taking her medications during medication administration observation. After the nurse left the room; Resident # 13 stated: I get a lot of medications. I like to be in my room by myself sometimes because I get sleepy, I drink a lot of coffee when I go downstairs to smoke. I am doing good now, I came from a Wheelchair to a walker. I was getting a medicine that make me so sleepy, and I am happy I don't get it anymore. I am here because I got hit by a car in [NAME] and this is the only place that will take me in. Record review revealed Resident #13 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13's clinical diagnoses include: fracture of the first lumbar vertebra, specifically a subsequent encounter for fracture with routine healing, traumatic hemorrhage of the cerebrum, Schizoaffective disorder bipolar ll disorder and a range of other conditions affecting her physical and mental health including treatment for hypertension and type 2 diabetes. Resident #13's medications ordered include but not limited: Remeron 45 mg (milligrams) at bedtime (antidepressant medication). Quetiapine Fumarate Oral Tablet 300 mg; one tablet by mouth two times a day (0800 and 1700) for Psychosis (antipsychotic medication). Risperidone Oral Tablet 1 mg one tablet by mouth two times a day (0800 and 1700) for Psychosis (an antipsychotic medication). Celecoxib (a muscle relaxer) Oral Capsule 100 mg, one capsule by mouth one time a day for Joint pain. Metformin 1000 mg, one tablet orally two times a day for Diabetes and Valproic Acid Oral Solution 250 mg /5 ml( milligrams per milliliters)10 ml by mouth three times a day for Seizures. Review of Resident #13's Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed Resident #13 is cognitively intact, show minimal or no depression, showed no behaviors and Psychosis ( hallucinations and delusions). Section for High-Risk Medications indicated the resident is taking high risk medications that include Antipsychotics and Antidepressants that are being taken routinely. The MDS indicated no GDR (Gradual Dose Reduction) had been attempted and section for Medication Follow-up documented: Not assessed/no information. During an interview on 03/27/2025 at 2:16 PM; the Psychiatrist was asked how frequently he visits the facility to see Resident #13 and if he receive report from staff and interact with the resident. He stated: I physically see all the residents and I see [Resident #13] every quarter like I see all my patients. I think I saw her in January. The Psychiatrist was asked to explain Resident #13's current Medication Regiment which include: Seroquel, Mirtazapine and Risperidone and if it is necessary for the resident to be taking this combination of high-risk medications based on the resident's history that include substance abuse. The Psychiatrist stated: She has calmed down and the medications are effective, when I go to see her she is doing pretty good, and she is able to tell me how she is doing. When asked if any attempts were made to a GDR on any of the medications. He stated: We are always getting recommendations .we declined attempting GDR because she does need the dosage she is taking, and we usually do the GDR once if the pharmacy recommend, only because we are forced/so we attempt. The Psychiatrist about the high dosage of Seroquel that Resident #13 is taking. He asked: What is the dose? The surveyor informed him that the resident is taking Seroquel 300 mg twice daily; the Psychiatrist was also asked about the Risperidone 1 mg twice per day and the Mirtazapine 45 mg. The Psychiatrist stated: I am wondering why I gave her the Seroquel and Mirtazapine, she may have been agitated and depressed; based on her behaviors at first when she was admitted because she was irritable and now she is laid back, and the last time I saw her she was doing better. I think that is why I have her each of these medications instead of only the Mirtazapine. I think I will decrease the Seroquel dose and Risperdal. On 03/27/2025 at 4:35 PM, interview with the Director of Nursing (DON); she revealed between 10/2024 and 11/2024 the Resident was observed drooling and sleeping, and could not do therapy and was not able to hold her cigarette. The DON revealed she called and informed the Psychiatrist that the Klonopin needed to be discontinued, and he discontinued the Klonopin on 12/04/25. Review of the Psychiatrist visit notes dated 12/04/2024 documented D/C (discontinue) all Klonopin. Review of Resident #13's Medication Regimen Review (MRR) with the DON revealed a recommendation documentation dated 7/31/2024 indicating: Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood or treat psych disorder. This resident has been taking Quetiapine 300 mg BID and Risperidone 1 mg BID. Could we attempt a dose reduction(s) at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: RESPONSE: previous, in facility, GDR failure OR Use is in accordance with relevant current standards of practice. Both options require clinical rationale for continuing by physician; stated below OR documented in the clinical record. The response was signed by the doctor on 08/19/2024. Further review of the Medication Regimen Review Log with the DON revealed no reviews completed for-08/2024, 09/2024,10/24, 11/2024, 12/2024. The DON acknowledged the concerns.

Based on observation, interview and record review the facility failed to ensure indwelling catheters are secure for two (Residents #7, and Resident #8) out of two residents reviewed for indwelling urinary catheter. As evidenced by Resident #7's was observed in the hallway carry his catheter bag in his hand and at times placing it on the floor. Resident # 8 was observed with the catheter's drainage bag on his lap and the tubing on the wheelchair's wheels. These deficient practices increases the risk for catheter related urological trauma if the indwelling urinary catheter is unintentionally pulled resulting in dislodgement. The findings include: Resident #7 On 03/27/2025 at 10:05 AM, Resident#7 was observed in the hallway with his indwelling catheter resting on his lap. At the time of the observation, there was no privacy bag in use to cover the catheter. (Photographic evidence) On 03/27/2025 at 11:28 AM, Resident#7's indwelling catheter was observed on the floor, the catheter was not properly secured or positioned. A staff member was noted performing 15-minute checks on residents, and did not notice the catheter bag on the floor (Photographic evidence) On 03/27/2025 at 03:00 PM, Staff X, Licensed Practical Nurse (LPN), entered Resident #7's room. The nurse picked up the catheter bag and placed it on the side of the bed while the resident was sitting in the wheelchair; if the resident were to roll the wheelchair, there was a potential risk of the indwelling catheter being dislodged. Review of the medical records for Resident #7 revealed the resident was initially admitted to the facility on [DATE]. Clinical diagnoses include but not limited to malignant neoplasm of the bladder, unspecified hydronephrosis, bladder-neck obstruction, benign prostatic hyperplasia without lower urinary tract symptoms and Alzheimer disease Review of Resident#7's Physician's Orders for March 2025 included but not limited to urinary catheter care every shift, Leg bag placed every morning; Catheter to be changed monthly and as needed for occlusion or leakage, drainage bag to be changed once a day for catheter care . Urine output should be monitored every shift. Enhanced Barrier Precaution: Applied as necessary for infection control. Medication ordered include Finasteride 5 milligram( mg) 1 tablet by mouth daily for Benign Prostatic Hyperplasia (BPH), Tamsulosin HCl: 0.4 mg 1 capsule in the evening for BPH. Record review of Resident #7 's Admission Minimum Data Set (MDS) dated [DATE] revealed: The resident has a brief interview mental status score of 00, indicating severe cognitive impairment. Functionally, the resident has bilateral upper extremity impairment but is independent in lower extremities, using a walker and wheelchair. The resident has an indwelling catheter, is not on a toileting program, and is frequently bowel incontinent. Active diagnoses include renal insufficiency, obstructive uropathy, bladder calculus, and other bladder-related conditions. Record review of Resident #7 's Care Plans Reference date 12/10/2024 and revised on 03/27/2025 revealed: The resident has an indwelling urinary catheter due to a bladder disorder, and the goal is to prevent catheter-related trauma. Interventions include positioning the catheter bag below the bladder and away from the door, checking for kinks in the tubing each shift, monitoring intake and output, and observing for signs of discomfort or infection. The resident has behavior issues related to noncompliance with the treatment regimen, including putting the indwelling urinary catheter tube around the neck and allowing the bag to drag on the floor, despite education and redirection. The goal for this behavior is to reduce episodes and avoid adverse consequences. Interventions include anticipating the resident's needs, educating the family and caregivers on coping strategies, explaining procedures, discussing inappropriate behaviors, and intervening as needed to ensure the resident's safety and comfort. Interview on 03/27/2025 at 02:56 PM, Staff X, LPN acknowledged that having the indwelling catheter's drainage bag on the floor was unacceptable due to the increased risk of infection and dislodgement. On 03/27/2025 at 3:06 PM, Staff T, Certified Nurse assistant and the Director of Nursing (DON) revealed they also made efforts to educate the resident about the risks of having the catheter on the floor and explained that the resident was confused and did not consistently follow their instructions regarding catheter care. During this interview Resident # 7 was observed ambulating unsteadily in the hallway holding the urinary catheter in his hand. Staff T assisted the resident back to his room and placed the catheter's drainage bag on the wheelchair. Resident # 8 On 03/27/2025 at 10:20 AM, Resident #8 was observed exiting the elevator with the indwelling catheter drainage bag on his lap and the tubing on the wheelchair's wheels increasing the risk for dislodgement and trauma if the indwelling catheter is unintentionally pulled out. On 03/27/2025 at 03:40 PM, Resident #8 was observed returning to his room after playing bingo, the catheter bag and tubing were positioned in close proximity of the wheelchair's wheels increasing the risk for dislodgement of the catheter. The DON was present and was shown the concerns; and revealed sometimes the resident move the catheter around. Review of the medical records for Resident #8 revealed the resident was initially admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Malignant neoplasm of prostate, obstructive and reflux uropathy, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident # 8's Physician's Orders Sheet for March 2025 revealed orders that include, Urinary catheter care is required every shift, catheter to be changed monthly or as needed for occlusion or leakage. Medications included Finasteride 5 mg daily for BPH and Furosemide 20 mg daily as a diuretic. Record review of Resident #8 's Admission Minimum Data Set (MDS) dated [DATE] revealed: The resident's brief interview mental status score is 13, indicating mild cognitive impairment. The resident does not have impairments in upper or lower extremities and uses a wheelchair. The resident has an indwelling catheter and is not on a urinary or bowel toileting program. Active diagnoses include obstructive uropathy and benign prostatic hyperplasia without lower urinary tract symptoms. Record review of Resident #8 's Care Plans Reference date 04/24/2024 and revised on 03/27/2025 revealed focuses on managing the resident's indwelling catheter due to obstructive and reflux uropathy. The goals are to prevent catheter-related trauma and avoid urinary infections. Key interventions include changing the catheter as needed, positioning the catheter bag properly, checking tubing for kinks, monitoring intake/output, and documenting symptoms of discomfort or infection .resident sometimes lets the indwelling catheter bag drag on the floor. The goal is to reduce these behaviors and prevent adverse consequences. Staff should monitor behavioral episodes and document potential causes to help manage future occurrences. 39177 On 03/27/2025 at 3:10 PM, the DON was asked about the usage of leg drainage bag for both residents. The DON revealed when the leg bag is in place the residents tried to remove it, but she will attempt to do so again.

Based on record reviews and interviews; the facility's Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, failed to ensure the designated Infection Preventionist who is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The facility's administrative staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads, failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents identified in residents' areas had the potential to spread diseases to residents and potentially affect 111 residents residing in this 120 bed facility. Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: A review of the facility's Administrator's job description signed on 04/04/2022 revealed the following: Delegate the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility, and ensures compliance with all state and federal regulations. Provide leadership to all facility staff to meet the goal of providing quality resident care. Schedule regular meetings with direct report staff to provide supervision, ensure communication, and monitor the facility. Ensure a safe, clean and comfortable environment for residents, visitors and staff. Maintain effective relationships and open communication with residents, families, staff, contractors, and the outside community. A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on [DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS), dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. In an interview conducted on 08/26/24 at 11:24 AM, Resident #9, stated that for the last 4 Saturdays there has not been any housekeeping services and the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the label) used for mice/rats in her room that was still in an unused packet sitting on top of her belongings. Resident #9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning area. In this interview, the Surveyor observed a white boxed container, which was located by the air-conditioning unit and was labeled for pests and roaches. According to Resident #9, the white box used for trapping pests did not work for rats or rodents, and this was why she kept requesting the pest control technician to get her the unused designated mice trap that was seen earlier on top of her belongings. During this entire interview, the Surveyor noted that food packaging that were opened on the over bed table, and other unsealed food items were around the bed. In an interview conducted on 08/29/24 at 7:20 AM with Staff OO, the Pest Control Technician stated that the facility does not have a Pest Control Log that he checks every time he comes into the facility for the specific locations and rooms that need treatments. The facility's Administrator reports all pest sightings verbally to him. The facility's Administrator only told him of rodent sightings for the first time last week. In an interview conducted on 08/26/24 at 1:30 PM with the facility's Administrator, she stated she was not aware of any rodents sighting in the facility and reported that any residents or staff members had not told her of any rodents in the facility. She further stated that Pest Control Services are here once a week, and she is in constant contact with the pest control technician. In an interview conducted on 08/29/24 at 7:53 AM, the Director of Nursing (DON) stated that he had never seen any rodents or rats in the facility but was told by Staff RR, a Registered Nurse who saw three rodents in room [ROOM NUMBER] which was on 06/27/24. The DON sent a message to the Administrator letting her know of the sighting which was reported by Staff RR. The Administrator told him that she would let Staff PP, the Former Maintenance Director who is no longer an employee with the facility, to take care of the issue According to the DON, he received multiple complaints of rodent sightings in the last six months from various staff members. Some staff members reported rodents coming out of the air-conditioning unit, but this was never verified. He always discussed these sightings in the department heads' meetings that are conducted daily, and the Administrator was aware of the rodent issue for the last six months. He was told by the facility's Administrator that the rodent issue would be handled in-house by the Maintenance Department rather than called a Pest Control Company. He did not document any of the reports or sightings from staff members and did not report the dates and times of the sightings. The DON stated that he expected the Administrator to take care of the rodent issue immediately, but she did not. Since he expected the Administrator to take care of the rodent concern, he did not notify the Health Department of the rodent infestation. He further reported that he is responsible for ensuring that the residents are kept in a safe, clean environment. He even discussed with the Administrator why she did not call the Pest Control Company but decided to take care of it in-house by the Maintenance Director. The Director of Nursing said that the Administrator was not overly concerned and said that she would have the in-house team take care of the rodents' sightings. In an interview with the Administrator on 08/29/24 at 8:00 AM, she revealed being was aware that Resident #9 reported seeing rodents in her room last Thursday and she told the pest control technician to treat Resident #9's room. The Administrator said they were going to deep clean the room and put all the food items in the room in tight plastic containers. In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, who started working in the facility in December of 2023 and left a month ago( July).; revealed the Administrator was aware of the rodent issue in the facility and was very involved in the pest control area before he was even hired. Around March of this year, he started getting reports of rodents sighting around the facility. He was not sure as to what arrangements were made with the Staff OO, the Pest Control Technician, and the Administrator, but Staff OO did not know of the rodent infestation in the facility. Staff OO visited the facility weekly, and they always discussed pest control issues. Staff OO never mentioned any rodent sightings reported to him by the Administrator. Staff PP received multiple complaints of rodents sighting by staff members which were not documented or written down in a pest control log. Most of the rodent's sightings were reported on the 2nd floor [NAME] Wing. He further revealed he never felt the support or leadership skills from the facility's Administrator. There were no systems in place to control the rodent's problem from the source. The in-house treatments that were done in some of the rooms did not resolve the problem and were only a temporary fix. Staff PP advised the Administrator to close the [NAME] Wing unit to treat the entire wing and eradicate the issue, which she refused. A chart review revealed Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE] with diagnoses of Dementia and Bipolar Disorder. The Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 12 which is mild cognitive impairment. In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, Registered Nurse stated she has worked in the facility for the last 13 months. Around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room; it was during medication administration, it was late in the evening when she noticed the rodents located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room.

Based on record review, observations, interviews, the Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, the administrative staff failed to follow infection preventions and control techniques and CDC (Centers for Disease Control) guidelines for How to Control Wild Rodent Infestations, the facility's administration staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads; failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents. The facility's failure to properly inspect, clean and remove food sources identified in 2 of 17 Residents' rooms (Resident #9 and Resident #36). Rats and mice are known to carry many diseases. This can cause a severe life-threatening disease, Mpox (virus that affects rodents, and causes a painful rash, enlarged lymph nodes and fever in humans), and rat-bite fever (causes fever, vomiting, headache, muscle, and joint pain, and rash in humans) which has the potential to affect 111 residents residing in the 120-bed facility. The facility failed to ensure that infection control procedures and guidelines were followed to properly handle the Glucometer for 1 of 1 resident reviewed for Blood Glucose Monitor Testing (Resident #48). The facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) guidelines were followed during wound care treatment for 1 of 1 resident observed for wound care (Resident #307). The facility failed to ensure a clear separation between the soiled linen area and the clean laundry areas to prevent cross-contamination during 2 of 2 observations of the laundry room. Facility failed to ensure designated Infection Preventionist who is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: 1) The Surveyor requested to review completed copy of specialized training in infection prevention and control from the Director of Nursing (DON), who was also assigned the infection Preventionist (IP). No certificate of completion was provided. Review of job description for DON/IP dated 10/31/23 sign by the DON/IP revealed that the Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of employment. An interview was conducted on 08/30/24 at 11:45 AM with the DON/IP. He stated he has worked at the facility since 10/31/23 and that he was not aware that he was assigned as the infection Preventionist until 2 months ago when the Administrator informed him to start the infection Preventionist modules. When asked if he had completed the entire IPCP training program and had a certificate, he stated that he started the modules but has not finished and has not obtained a certificate. Review of the facility's job description titled, Infection Preventionist, included the following: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Infection Control and Prevention Program in accordance with current federal, state, and local standards, guidelines, and regulations that govern our center and as may be directed by the Medical Director or Director of Nursing (DON) to ensure that the center provides a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections. Experience: Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of employment. 2) During an observation conducted on 08/26/24 at 11:50 AM, two Surveyors were on the 2nd floor [NAME] Wing hallway across from Resident #9's room. Upon exiting the room across, they observed a rodent running in the [NAME] Wing hallway toward Resident #9's room. Further observation revealed Resident #9 was sitting in her wheelchair in the hallway. She was noted lifting one leg to avoid touching the rodent with her feet. Resident #9 then said to the Surveyors, There it is. Did you see it? as she pointed at the rodent running into her room. Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with diagnoses that include: Hemiplegia, Muscle Weakness, and Gout. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. During an interview conducted on 08/26/24 at 11:24 AM with Resident #9, she stated that for the last 4 Saturdays, there had not been any housekeeping services and that the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. During this entire interview, the Surveyor noted that food packaging was opened and laying on the overbed table, and other unsealed food items were around the bed and on the bedside table. During an interview conducted on 08/29/24 at 7:53 AM with the DON/IP, he stated that he had never seen any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a resident's room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM NUMBER] running around by the window. She further said to him that she witnessed 2 out of 3 medium-sized rodents who were not fully grown and who went by her very fast. This sighting was passed to the Administrator, who said she would handle the issue. During an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that she was aware that Resident #9 reported seeing rodents in her room last Thursday. The Administrator stated that they are going to treat the entire room, take all furniture and belongings out, and look for possible openings and holes. According to the facility's administration, Resident #9 has been in the facility for [AGE] years, and her family brings her groceries every week, which are stored all around her room. During an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room. It was late in the evening, during medication administration, when she noticed the rodents were located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room. Any rodents or pest sightings are documented on the pest control log in the nurse's station. When asked if she had documented the sighting in the pest control log, she said no. Record review for Resident #36 revealed that the resident was admitted to the facility on [DATE] clinical diagnoses include: Dementia, Bipolar Disorder. Review of the MDS dated [DATE] revealed a BIMS score of 12, which was slight cognitive impairment. Review of the CDC's How to Control Wild Rodent Infestations, 01/03/23, https://www.cdc.gov/healthy-pets/rodent-control/index. html included in part the following: Rodents, such as rats, mice, and chipmunks, are known to carry many diseases. These diseases can spread to people directly, through: Handling of rodents. Contact with rodent droppings (poop), urine, or saliva. Rodent bites. Rodent droppings, urine, and saliva can spread by breathing in air or eating food that is contaminated with rodent waste. Rodents can also carry ticks, mites, or fleas that can spread diseases. Review of the facility's policy titled, Pest Control Services, dated 12/08/23, included the following: A program will be established for the control of insects and rodents within the facility. Procedure: 1. The Administrator coordinates with the Maintenance Department to arrange pest control services on a monthly basis, or as needed. 2. Food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin 3) Record review for Resident #48 revealed that the resident was admitted to the facility on [DATE] diagnoses that include: Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #48 had a Brief Interview for Mental Status of 07, which indicated that he was severely cognitively impaired. Review of the Physician's Orders showed that Resident #48 had an order dated 04/24/24 for Humalog KwikPen Subcutaneous Solution Pen-injector 100 Unit/ml (Insulin Lispro), Inject as per sliding scale before meals and at bedtime for DM. Injector 1 Fingerstick blood glucose monitoring QID (four times a day) before meal and at bedtime for Diabetes Mellitus (DM). On 08/27/24 at 4:00 PM observation of blood glucose monitoring test (Accu-Chek) conducted by Staff WW, Licensed Practical Nurse (LPN) Staff WW gather all the following supplies: Glucometer, 2 alcohol wipes, lancet, a container of blood glucose test strips, and placed them all on a foam tray. She entered the room for Resident #48, washed her hands, donned gloves, placed the foam tray on the bedside table, and performed the Accu-Chek on Resident #48. She then, placed the dirty Glucometer and the container of blood glucose strips back on the foam tray and walked outside of the room to discard the used lancet into the sharp's container. Staff WW returned to Resident #48's bedside table, placed the dirty Glucometer and the container of blood glucose strips into her uniform pocket and threw away the foam tray, then walked to the bathroom and washed her hands. She exited Resident #48's room and removed the dirty Glucometer and the container of blood glucose strips from her pocket and placed them on top of her medication cart. Staff WW donned gloves, bleach wipes and cleaned the dirty Glucometer and sat it on top of Medication cart to dry. When asked why she placed the dirty Glucometer in her pocket, Staff WW stated that she had no place to carry it, and she needed to wash her hands. Review of the CDC's Infection Prevention during Blood Glucose Monitoring and Insulin Administration, 02/06/13, https://www.cdc.gov/celiac/docs/addenda/celiac/07b_celiac_2013march_glucose_monitoring Blood Glucose Meters: General: Whenever possible, blood glucose meters should be assigned to an individual person, and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets. 4) Record review for Resident #307 revealed that the resident was admitted to the facility on [DATE], clinical diagnoses include but not limited to: Type 2 Diabetes Mellitus with other Specified Complication; Pressure Ulcers. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #307 had a Brief Interview for Mental Status of 11, which indicated moderate cognitive impairment. Review of the Physician's Orders showed that Resident #307 had an order dated 07/04/24 for Enhanced Barrier Precautions every shift for Wounds PPE (Personal Protective Equipment) required; Wound care Cleanse the wound with Dakins and pat dry with gauze. Apply Santyl to the wound bed followed by alginate. Cover with foam with silicone bordered dressing daily and PRN (as needed) for soiled or loose dressing. Collagenase Ointment 250 Unit/GM, apply to Left Posterior Groin topically as needed for Wound care Cleanse the wound with Dakins and pat dry with gauze. During a wound care observation conducted on 08/28/24 at 2:48 PM, Staff XX, Licensed Practical Nurse (LPN) noted she has been working at the facility for 3-4 months as the wound care nurse. Staff XX was observed gathering the following supplies from the wound care cart: a hand sanitizer pump, gloves (placed on a foam tray), gauzes, a cup of the powered medication (alginate), and a cup of clear liquid (Dakin's solution). She entered Resident #307's room and set-up the supplies on the over-bed table that was covered with a chuck pad. Staff XX went to the bathroom, washed her hands and returned to the bedside and donned on double gloves (no gown was donned). She soaked gauze with the Dakin's solution and cleaned the groin area, removed the top pair of gloves, leaving bottom pair of gloves on and donned a new clean pair of gloves over dirty pair that remained on her hands. Staff XX continued to double glove and don clean gloves over the dirty pair of gloves at least six times during the wound treatment procedure. In addition, Staff XX was observed in the bathroom washing her hands, used a small bottle (which she thought it was soap, however it was labeled hand sanitizer) to wash her hands. She then stated that the soap dispenser has not been working. Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 04/02/24, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html included in part the following: Enhanced Barrier Precautions (EBP) Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing. Review of the CDC's Clinical Safety: Hand Hygiene for Healthcare Workers, 02/27/24, https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html included in part the following: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. During an interview conducted on 08/28/24 at 3:00 PM, Staff XX was asked why she did not wear a gown during the wound treatment, she just lowered her head and shrugged her shoulders. In addition, she was asked why she did not perform hand hygiene after removing her gloves, Staff XX stated that the hand sanitizer dries her hands, so she does not use it and that's why she wore double gloves. Review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated April 2013, included the following: To provide guidelines for general infection control while caring for residents. General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents. d. after removing gloves. 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents. f. Before moving from a contaminated body site to a clean body site during resident care. j. After removing gloves. 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 5) An observation was conducted on 08/26/24 at 10:48 AM of Staff I, Certified Nursing Assistant (CNA) dumping an open bag of dirty laundry down the 3rd floor laundry chute. During an interview conducted on 08/26/24 at 10:49 AM, Staff I was asked if she just dumped dirty laundry down the chute in an open bag, she stated yes. She acknowledged that sometimes she does dump dirty laundry down the laundry chute in an open bag and sometimes she does not. During this interview, the Assistant Director of Nursing (ADON) approached Staff I and stated that the dirty laundry should always be in a closed bag before dumping it down the laundry chute. Review of the facility's policy titled, Laundry Services- Handling/Storing/Transporting Linen, dated 12/08/23, included the following: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Procedure: Standard Precautions 1. Separate soiled and clean linen at all times. Bagging and Handling/Sorting Soiled Linen: 1. All soiled linen must be placed directly into a covered container designated for soiled linen and/or plastic bag which can contain the moisture. 4. Handle soiled linen as little as possible to prevent agitation. 5. Employees sorting or washing linen must wear a gown and gloves. Washing Linen and other Soiled Items: 5. Keep soiled and clean linen, their respective hampers and laundry carts, separate at all times. 7. Wash mops separately from linens, using bleach/EPA registered germicidal A tour of the facility's laundry room was conducted on 08/30/24 at 10:20 AM with the Maintenance Director and the Environmental Director. Upon entering the laundry room, it was noted that Staff EE, laundry aide, was not wearing personal protective equipment (PPE) and she was about to load soiled linen into the washer. She realized that the surveyor had entered the laundry and donned on a gown. The laundry was a small room that had 2 washers and 2 dryers (no separation between the contaminated linens and the clean laundry areas). There was an attached room for receiving the soiled laundry via the chute from the 2nd and 3rd floor, and another room where residents' clean clothing is sorted and stored; both room doors were propped open. In addition, there were 4 labeled laundry carts used to transfer linens between the soiled room, the washers, the dryers and the clean clothing room. Further observation revealed one of the carts was filled with clean dry residents' clothing, however, the cart was labeled for soiled linens. During an interview conducted on 08/30/24 at 10:30 AM, Staff EE stated she sorts the soiled linens and residents' clothing by color in the container in the soiled/chute room (the clothing are left inside the container until enough accumulate of the same color). Observation of the soiled room revealed that the chute and container were filled with soiled linen and residents' clothing; some of the clothing were in plastic bags and some were not. Staff EE acknowledged that the space is small and not divided, however, the staff is aware which cart to use for soiled linen versus clean linen since they are labeled. On 08/30/24 at 3:15 PM, a 2nd visit to the laundry room was conducted; only one laundry aide was observed in the room, Staff K, housekeeping and laundry aide. The surveyor noted a laundry basket overflowing with wet clean linens (hanging out of the basket and very close to the floor). Staff K stated that she was not sure why the other dryer was not working and was waiting for the one dryer currently working.

Based on observations, interviews, and record reviews, the facility's administrative staff failed to implement, maintain, and measure an effective pest control program to eradicate and contain rodent infestation. Facility administrative staff was unable to address rodent sightings in a timely manner. The facility's administrative staff failed to follow their own policy for pest control and educate staff members appropriately. These diseases can spread to people directly through the handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. This had the potential to affect 111 residents residing in this 120-bed capacity facilities. The system failure to ensure pest control/infection control and prevention interventions and services were effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were determined to be ongoing on 8/30/2024. The findings included: A review of the facility policy titled Pest Control Services dated 12/08/23 showed the following: A program will be established to control insects and rodents within the facility. The Administrator coordinates with the Maintenance Department to arrange pest control services monthly or as needed. Staff should report to the Administrator and Maintenance Department sightings of live pests, which are documented in the pest control log. Food preparation, service, and storage areas will be monitored regularly for any signs of pests or vermin. The Administrator and Maintenance Department will be notified immediately of any concerns. A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on [DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS), dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair. A chart review revealed that Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE] with diagnoses of Dementia, Bipolar Disorder. The MDS dated [DATE] revealed a BIMS score of 12, which was slight cognitive impairment. In an interview conducted on 08/26/24 at 11:24 AM, Resident #9 stated that for the last 4 Saturdays, there had not been any housekeeping services and that the place was dirty. The facility's Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the label) used for mice/rats in her room that was still in an unused packet sitting on top of her belongings. Resident #9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning area. In this interview, the Surveyor observed a white boxed container, which was located by the air-conditioning unit and was labeled for pests and roaches. According to Resident #9, the white box used for trapping pests did not work for rats or rodents, and this was why she kept requesting the pest control technician to get her the unused designated mice trap that was seen earlier on top of her belongings. During this entire interview, the Surveyor noted that food packaging was opened over the bed table, and other unsealed food items were around the bed. In an observation conducted on 08/26/24, at 11:50 AM, Two Surveyors were on the 2nd floor [NAME] Wing hallway across from Resident #9' room. Upon exiting the room across, they observed a rodent running in the [NAME] Wing hallway toward Resident #9's room. Resident #9, who was sitting in her wheelchair in the hallway, lifted one leg to avoid touching the rodent with her feet. Resident #9 then said to Surveyors, There it is. Did you see it? as she pointed at the rodent running into her room. In an interview conducted on 08/26/24 at 1:30 PM, with the facility's Administrator, she stated she was not aware of any rodents sighting in the facility and reported that she was not told by any residents or staff members of any rodents in the facility. A chart review revealed Resident #9's roommate, Resident #96, was admitted to the facility on [DATE] with diagnoses of Altered Mental Status, Dementia, and Cerebral infarction. The MDS dated [DATE] showed a BIMS score of 14, which was cognitively intact. In an interview conducted on 08/26/24 at 12:10 PM with Resident #96, she was not able to answer any of the Surveyor's questions regarding the rodent sighting. In an interview conducted on 08/26/24 at 1:07 PM with Staff PP, the Psychologist stated that she had not seen any rodents in the facility but was told by several residents that they observed rodents in the facility. A review of the Pest Control service reports showed the following: On 02/1/24, a pest control service report showed that a routine rodent control service was provided. On 03/7/24, a pest control service report that showed a routine rodent control service was provided. On 4/4/24, a pest control service report that showed a routine rodent control service was provided. On 05/02/24, the pest control service report showed that a routine rodent control service was provided. On 06/6/24, a pest control service report that showed a routine rodent control service was provided. On 07/11/24, a pest control service report showed that a rodent control service was provided for exterior perimeter rodent control for roof rats. On 08/01/24, the pest control service report showed that a routine rodent control service was provided. In an interview conducted on 08/29/24 at 6:28 AM with Staff OO, Pest Control, he stated that he had been coming to the facility four times a week for the last seven months. When asked if he had seen any rodents in the facility, he said no and that he had not seen any rodent droppings. Staff OO stated that Resident #9 told him that she saw a rodent in her room near the window by the air-conditioning unit last Thursday. He then placed two glue traps in the room by the air-conditioning unit. Staff OO stated that during the above routine rodent control services conducted monthly, he checks on the five black rodent control boxes that are placed outside the facility perimeter. These boxes are checked once a month for any activities or sighting of rodents. He never found any rodents inside the black boxes, but he did see some activities inside the boxes indicating that rodents took the bates that were placed in these boxes. The rodent trap boxes are part of a routine service for preventative measures. According to Staff OO, once a week for his visits is sufficient, but twice a week would be better. He had reports of rodents being seen in the main kitchen about two months ago, and he placed traps. Staff OO did not see any rodent activities or capture any rodents from the traps that he placed in the main kitchen. According to Staff OO, the facility does not have a Pest Control Log that he checks every time he comes into the facility to review the areas and rooms that need to be sprayed or treated. The staff tells him verbally about the areas that need treatment when he comes into the facility. In an interview conducted on 08/29/24 at 7:53 AM with the Director of Nursing (DON), he stated that he had never seen any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a resident's room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM NUMBER] running around by the window. She further said to him that she witnessed 3 medium-sized rodents who were not fully grown and who went by her very fast. This sighting was passed to the Administrator, who said she would handle the issue. An overnight staff member whose name he did not know told Staff SS, Medical Records, that she saw a rodent on the 2nd floor but did not give any specific room or location of this sighting. In an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that he verbally tells Staff OO of pest control issues and sightings when he comes for his weekly visits. According to the Administrator, it is not written on any pest control logs. She was aware that Resident #9 reported seeing rodents in her room last Thursday, and she told Staff OO to treat the room. The Administrator stated that they are going to treat the entire room, take all furniture and belongings out, and look for possible openings and holes. According to the facility's administration, Resident #9 has been in the facility for [AGE] years, and her family brings her groceries every week, which are stored all around her room. In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, the Former Maintenance Director stated that he started working in the facility in December of last year and left the facility a month ago. He was told by Staff QQ, Maintenance Staff, that Resident #36 had rodents running around her room. Staff QQ placed glue traps in Resident #36's room to try to trap the rodents, but this did not work since rodent sightings were still noted in the room. In March of 2024, he started getting multiple complaints of rodents around the facility from multiple staff members who reported sighting, but none of the sightings were documented in a pest control log. Most of the rodent sightings were coming from the 2nd floor [NAME] Wing. In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported that she has been working in the facility for the last 13 months. Around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's room. It was late in the evening, during medication administration, when she noticed the rodents were located at the end of the room. The DON told her that he would let management know of the rodent's sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room. Any rodents or pest sightings are documented on the pest control log in the nurse's station. When asked if she had documented the sighting in the pest control log, she said no. In an interview conducted on 08/29/24 at 9:52 AM with Staff SS, Medical Records stated that she was unaware of any rodents sightings in the facility or any other staff members reporting sighting of rodents. She denied any staff telling her verbally or via text messages of any rodents sightseeing in the facility. When asked about the policy for pest sightings, she said that she would tell the Administrator and Maintenance staff. When asked if she was part of any group chat regarding the facility, she said yes. In an interview conducted on 08/29/24 at 10:04 AM with Staff QQ, Maintenance staff reported that he has been working in the facility since 2001. He has never seen any rodents around the facility and was never told by any staff members or residents of any rodent sighting. Staff PP never told him about the rodents that were sighted in Resident #36's room. Staff QQ stated that he looks at the pest control log located on each unit for any pest control issues or sightings from staff. He knows that the Pest Control technician comes into the facility on ce a week but does not know what was treated and which areas. In another interview conducted on 08/29/24 at 10:10 AM with Staff SS, she reported that after she was done with the earlier interview on 08/29/24 at 9:52, she suddenly remembered that a staff member said to her that they saw a rodent on the unit which was on 08/20/24. She did not know the name of the staff member who told her but knew that they worked the night shift. Staff SS sent the information to the facility's group chat. In an interview conducted on 08/29/24 at 10:18 AM with Staff TT, Physical Therapy Assistance stated that she had never seen any rodents in the facility. This week, she was told of a rodent sightseeing, which was observed by Surveyors and Resident #9. She is part of a group chat from the facility by all department heads. She read on the group chat that a rodent was seen by a staff member last week, on 08/20/24. The facility's Administrator was aware of these sightings.

Based on record review, observations and interviews, the facility failed to follow the doctor's orders for tube feeding administration, complete a nutritional assessment, and identify a severe weight loss for 1 of 1 resident reviewed for tube feeding (Resident #210). The findings included: Resident #210 was admitted to the facility on [DATE] with diagnoses of Seizures, Dementia, Hypertension, and Protein Calorie Malnutrition. Hospital records dated 08/07/24 (8 days before his admission to the facility) showed the following: Resident #210 presented to the hospital with lethargy, lack of appetite, poor intake of meals, and Altered Mental Status. Resident #210 ' s daughter agreed to move forward with a Percutaneous endoscopic gastrostomy (PEG) placement. The Speech Language Pathologist deemed inappropriate for food by mouth trials and at high risk for aspiration. Upon physical exam, Resident #210 ' s weight was 132 pounds. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #210 has severe cognitive impairment. A review of the physicians ' orders showed an order for enteral feeding Jevity 1.5 (tube feeding formulary) and bolus feeding six times a day, which started on 08/16/24. The bolus tube feeding regimen times are to be given at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 9:00 PM. A can of Jevity 1.5 provides 355 calories/can and 15.1 grams of protein/can. This above order will provide 2130 calories a day and 90.6 grams of protein if six cans of Jevity 1.5 are given as ordered. A review of Resident #210's electronic chart showed that no initial nutritional assessment was completed for Resident #210, and no admission weight was taken on Resident #210. In an interview conducted on 08/27/24 at 12:30 PM with Staff AA, the Clinical Dietitian stated that she completed Resident #210 ' s initial nutrition assessment on 08/25/24 but did not know why it was not in the electronic system and could not provide a copy of the evaluation to this Surveyor. She further said she completes an initial nutrition assessment within seven days of admission. If the residents are at high nutritional risk, she will try to complete the assessment sooner. Staff AA said that she did not have an admission weight obtained on admission for Resident #210 and was unaware of Resident #210 ' s weight history. In an interview conducted on 08/27/24 at 2:30 PM with Staff HH, a Certified Nursing Assistant (CNA) stated that a designated CNA (Staff GG) takes the weights on all residents. In an interview conducted on 08/27/24 at 2:47 PM with Staff FF, Registered Nurse, she reported Resident #210 is tolerating his bolus tube feeding well with no issues. In an interview conducted on 08/27/24 at 2:55 PM with Staff GG, CNA stated that the weights are taken and given to the assigned Nurse to put in the electronic system. Sometimes, the CNA assigned to the specific resident will take the weight on the resident. Staff GG said that she only sometimes takes the weights on all residents and that she is sometimes given other duties and assignments. When residents get admitted or readmitted their weights are taken the same day or the day after. The weights are monitored on a monthly basis, and sometimes, they are monitored on a weekly basis, depending on the specific resident. This Surveyor requested a new weight on 08/27/24 at 3:10 PM. The weight showed that Resident #210 was 109.8 pounds, which revealed a 17% severe weight loss in less than one month. In an observation conducted on 08/28/24 at 8:20 AM, Resident #210 was noted in bed with no tube feeding running at the time of this observation. In an interview conducted on 08/28/24 at 8:10 AM with Staff CC, a Registered Nurse (RN) was asked about the scheduled bolus tube feeding times for Resident #210. She said that the night Nurse who worked the 11:00 PM to the 7:00 AM shift did not tell her when the last bolus tube feeding was given. Staff CC then proceeded to look in the physical paper chart for Resident #210 ' s tube feeding order. Staff CC reported that the tube feeding was not clear and that she needed to look at the electronic records for an accurate tube feeding order. After a few minutes of trying to look for Resident #210 ' s tube feeding order in the electronic system, she turned to the Assistant Director of Nursing (ADON), who was next to her, to help her find the tube feeding order in the electronic system. The ADON was observed helping Staff CC look for Resident #210 ' s tube feeding orders in the electronic system. Staff CC verified that the bolus tube feeding regimen times are given at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 9:00 PM. In an observation conducted on 08/28/24 at 8:20 AM, Resident #210 was noted in bed with no tube feeding running at the time of this observation. In an interview conducted on 08/28/24 at 8:26 AM, the ADON stated that Staff CC usually works on different floors and was unfamiliar with Resident #210. She said that the 11:00 PM to 7:00 AM shift Nurse should have communicated the tube feeding times and orders to Staff CC. In an observation conducted on 08/28/24 at 9:00 AM, Resident #210 was noted in bed with no tube feeding running in the room. In an observation conducted on 08/28/24 at 9:30 AM, Resident #210 was noted in bed with no tube feeding running in the room. In an observation conducted on 08/28/24 at 9:40 AM, Staff CC noted feeding Resident #210 his bolus tube feeding order, which was 1:40 minutes later than his scheduled feeding time of 8:00 AM. In an observation conducted on 08/28/24 at 11:00 AM, Resident #210 was noted in bed with no tube feeding running at the time of this observation. In an interview conducted on 08/28/24 at 12:25 PM, with Staff, CC stated that she was just getting ready to give Resident #210 his tube feeding since she gave the earlier feeding late. A phone interview conducted on 08/28/24 at 1:00 PM with Resident #210 ' s daughter stated that her father was 138 pounds about one month ago. She further stated that she is waiting on a Modified Barium Swallow (MBS) exam to assess for possible diet upgrade by mouth which he was in the past. In an interview conducted on 08/28/24 at 2:45 PM, with Staff CC reported she still needs to give Resident #210 his tube feeding bolus feeding since the last bolus feeding was given at 12:30 PM. She further said that she only gives one bottle of tube feeding at a time as per the Physician ' s orders and does not give two bottles to compensate for the late times. A progress note dated 08/22/24 by the Physician revealed the following: Resident #210 with a history of Dementia and Protein Calorie Malnutrition. The care plan initiated on 08/27/24 showed that Resident #210 was at risk for alteration in nutrition and hydration related to malnutrition/risk for malnutrition and tube feeding. Resident #210 will eat above 50% of his meals daily through the next review date. Diet as ordered, cue, set up, and assist as needed with meals. A review of the Medication Administration Audit Report for Resident #210 revealed the following: On 08/22/24, the tube feeding scheduled for 9:00 PM was given at 10:20 PM, which was one hour and 20 minutes later. On 08/23/24, the tube feeding that was scheduled to be given at 5:00 PM was given at 6:36 PM, which was 1 hour and 36 minutes later. On 08/23/24, the tube feeding that was scheduled to be given at 9:00 PM was given at 11:07 PM, which was 2 hours and 7 minutes later. On 08/24/24, the tube feeding was scheduled to be given at 9:00 PM and was given at 1:02 AM, which was 4 hours and 2 minutes later. On 08/26/24, the tube feeding was scheduled to be given at 9:00 PM and was given at 4:58 AM, which was 7 hours and 58 minutes later. On 08/27/24, the tube feeding was scheduled to be given at 8:00 AM and was given at 12:06 PM, which was 4 hours and 6 minutes later. On 08/27/24, the tube feeding was scheduled to be given at 11:00 AM and was given at 12:14 PM, which was one hour and 14 minutes later. On 08/27/24, the tube feeding was scheduled to be given at 9:00 PM and was given at 12:50 AM, which was 3 hours and 50 minutes later. A review of the electronic record on 08/28/24 showed that Resident #210 did not complete an initial nutrition assessment, which was 13 days after his admission. A review of the facility's policy titled Nutrition Policy dated 09/07/2023 revealed the following: A Registered Dietitian or other clinically qualified nutritional professional is responsible for the completion of a comprehensive nutrition assessment for all residents/patients for the purpose of identifying and planning the nutrition care based on the needs, goals, and preferences of each resident/patient. The resident/patient nutrition status will be assessed upon admission and monitored at least quarterly thereafter. A review of the facility ' s policy titled Weight Management-Residents titled 12/2008 revealed the following: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure the residents ' weights on admission/readmission. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where the percentage of body weight loss = (usual weight -= actual weight) / (usual weight) X 100]: a. month -= 5% weight loss three months -- 7.5% weight loss six months -- 10% weight loss.

Based on record reviews, observation,and interviews, the facility failed to prevent the neglect of one (Resident #1) out of six residents sampled documented for elopement risk. The facility's failure in ensuring an adequate alert monitoring system was in place and staff's negligence in ensuring supervision and failure in implementing measure to prevent the elopement of Resident #1 who was care planned as an elopement risk. Resident #1's exited the facility undetected on 07/17/2024 through the facility's laundry room door that was not latched by staff. Resident #1 who was last seen between 7:00 PM and 7:30 PM was located at approximately 2:30 AM by local law enforcement at the county dump site one and a half miles (1.5) from the facility). The facility is a three-story building with residents rooms on the second and third floor; located in an area that has high traffic volume, busy intersections and is in a residential area. The county dump site (1.5 miles from the facility) has 2-way traffic, with a 40 miles per hour speed zone traffic. The resident has risk factors that that could likely have resulted in an adverse outcome based on the resident's clinical diagnoses The findings included. Records reviewed revealed on 07/17/2024 Resident #1 who has exit seeking behavior and wanders was not adequately supervised and left his room on the second floor, took the elevator to the first-floor laundry room and exited the facility through the unlocked door in the laundry room. On 07/29/2024 at 10:25 AM Resident #1 was observed in his room seated on his wheelchair in his room watching television with assigned one to one (1:1) Certified Nursing Assistant (CNA) Staff A. Interview on 07/29/2024 at 10:26 AM; Staff A reported the resident is not agitated and she will take the resident to activities. On 07/30/2024 at 10:45 AM; Resident#1 was sleeping, and no distress was noted. Staff A reported the resident requested to be in bed and at lunch time she will wake up the resident. Review of Resident #1's clinical records revealed, an initial admission to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but not limited to, Alzheimer's Disease with Late Onset; Altered Mental Status; Dementia; Restlessness and Agitation. Resident #1 who was listed as an elopement risk had was being monitored for behaviors that were being documented on the Medication Administration Records (MAR) by the day and night shift. The Quarterly Minimum Data Set (MDS) 07/05/2024 documentation indicated a Brief Interview of Mental Status (BIMS) score of 00 out of 15 to suggest the resident has severe cognitive impairment; Section E for Behaviors documented the resident exhibited wandering behaviors. Review of Resident #1's Care Plan initiated on 2/21/2024 with next review date 10/5/2024 revealed: The resident is an elopement risk/wanderer related to History of Elopement, Dementia, Disoriented to Place, History of Attempts to Leave Facility Unattended, Impaired Safety Awareness, Resident Wanders Aimlessly, Significantly Intrudes Privacy or Activities. Goal: The resident will not leave facility unattended through the review date. The residents' safety will be maintained through the review date. Interventions: Distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Increased supervision (Resident is on 1:1 supervision always). Monitor location frequently. Document wandering behavior and attempted diversional interventions. Place resident's picture, and information in Elopement Book. Review of the Federal Report #644710 revealed: On 07/17/2024 between 7:00 PM to 7:30 PM Resident #1 was seen by Staff D Certified Nursing Assistant, after she provided care for him. She reported she took the resident downstairs from the third floor to the second floor to get him ready for bed, after she gave him care, she left, and he left his room shortly afterwards. He usually can be found walking up and down slowly on the second-floor hallway. He sometimes wanders into other resident rooms, but he is easily redirected when that occurs. He sometimes sits on the floor and was once found hiding in a closet in a resident room. When the nurse went to give him his medications between 8:00 PM and 8:30 PM she noticed that he was not in his room, and she began to look for him throughout the second floor. When he could not be located, she called the third floor and asked for them to look for him. 9:00 PM Staff were looking for the resident for 30-40 minutes. Once everywhere was checked and he still could not be located, the nurse notified the Registered Nurse (RN) Supervisor who was onsite at around 9:00 PM. The RN supervisor then began to search for him. He looked in every room, bathroom, office, dining room, break room, daycare, laundry, therapy, etc. He then got in his car and drove around the area. The facility then called the police and notified the resident's son and physician. The police showed up at around 12:00 AM. While onsite the police got a call over the radio at about 2:30 AM that he was located at the county dump. The security guard at the dump observed him enter the property on foot. He approached him and noticed the resident was confused. The security guard asked the resident his name and Resident # 1 gave his name the security guard gave the police officer the name. The police already had patrol cars in the area looking for him, so they went there and picked him up. They brought him back to the facility at about 2:45 AM. During an interview on 07/29/2024 at 3:40 PM the Chief Nursing Officer revealed, the Administrator texted her on 07/17/2024 at 11:17 PM. The Administrator informed her one resident was missing and all-staff member were looking for him, they were looking in all rooms in the facility, the lobby dining rooms etc. The Administrator called the police department, and a police officer arrived at the facility; and the resident was found around one and a half miles from the facility at the county dump site. The police took the resident back to the facility. The Administrator informed her when the resident was taken back to the facility. The administrator decided to send the resident to the hospital for further evaluation. She stated the resident come back from the hospital on the same date with no injuries, Interview with Staff C Registered Nurse/Supervisor (RN) on 07/29/2024 at 3:56 PM. He reported the nurse approached him and informed him [Resident # 1] was missing they started to search for the resident on every floor. They search all rooms, under the bed and in the closets because the resident has a tendency to hide under the beds and inside the closets. When they finished looking for the resident on the second and third floors, they came down to the lobby and realized the laundry room was not latched. They went to the laundry room and saw the exit door open, that exit door goes to the parking lot and the street. He then called the Director of Nursing and the Administrator. They search around the area outside the facility. When the resident was not found the police was called and the resident was reported missing. Interview on 08/01/2024 at 3:45 PM the Director of Nursing (DON) reported; the Nurse Supervisor called him at approximately 10:00 PM and he was informed that a resident was missing, and staff were looking for the resident in all areas of the facility, and outside the facility. When he arrived at the resident eloped through the laundry room door that was not latched. The DON reported he went around the area in his car looking for the resident. The police found the resident and took him back to the facility around 2:45 AM and the resident was transferred to the hospital for evaluation. The back to the facility the same date with no injuries. He reported Immediate Jeopardy removal plan included unannounced elopement drills every other day in different shifts and in-services education for the staff. All residents were reassessed for risk of elopement initiated 7/17/2024 and completed 7/18/2024. There was a facility wide head count of current residents completed 7/17/2024. One resident eloped and was unaccounted for until 7/18/2024. All the facility doors were immediately checked to ensure proper functioning by the Administrator on 7/17/2024. All doors are checked 7 days a week to ensure proper functioning by a department head initiated 7/18/2024. The resident was placed on 1:1 supervision as of 7/18/2024 and will remain on 1:1 supervision until further assessment by the physician and psych services. The laundry staff who did not latch the door properly was educated by the Administrator 7/18/2024. Residents at risk for elopement have names and photos in a binder at the front desk and nursing stations are at 100% as of 7/17/2024. Care Plans were reviewed for current residents at risk for elopement and will have individualized interventions as of 7/17/2024. There is a dedicated staff member to monitor the front lobby area 24 hours 7 days a week with documentation that was initiated on 07/17/2024 and ongoing, hourly checks are being done for all elopement risk residents initiated 7/18/2024. The department manager will complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for was initiated on 7/18/2024. A screamer alarm was placed on the identified laundry room door 7/18/2024. The facility's Immediate Jeopardy Removal Plan was verified through records reviewed and interviews. The removal plan included: The immediate actions taken to remove the Immediate Jeopardy related to F600 based upon root cause analysis: 1-100% of all current residents reassessed for risk of elopement initiated 7/17/2024 and completed 7/18/2024. 2-100% facility head count of current residents completed 7/17/2024. One resident eloped and was unaccounted for until 7/18/2024. 3-All facility doors were immediately checked to ensure proper functioning by the Administrator on 7/17/2024. 4-Doors are checked 7 days a week to ensure proper functioning by a department head initiated 7/18/2024. 5-Resident was placed on 1:1 supervision as of 7/18/2024 and will remain on 1:1 supervision until further assessment by the physician and psych services. 6-Facility to conduct unannounced drills 4 x a week to include off shifts and weekends initiated 7/17/2024. 7- Laundry staff who did not latch the door properly was educated by the administrator 7/18/2024. 8-Residents at risk for elopement have names and photos in a binder at the front desk and nursing stations are at 100% as of 7/17/2024. 9-Care Plan reviewed and current for residents at risk for elopement to include individualized interventions as of 7/17/2024 10-Dedicated staff member to monitor the front lobby area 24/7 with documentation initiated 07/17/2024 and ongoing. 11-Hourly checks for all elopement risk residents initiated 7/18/2024. 12-A department manager to complete a head count of all residents upon arrival and before leaving five times a week to ensure all residents are accounted for initiated 7/18/2024. Staff to be educated upon hire, annually and as indicated based on facility need related to the Elopement and Abuse / Neglect policies. Quote initiated for a keypad type system for the elevator 7/29/2024. [Wander management alarm] vendor contacted, and initial phase of quotes and equipment needed initiated 7/31/2024. Residents identified as at risk for elopement will be monitored by the electronic tracking system. The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring r/t the above listed elements of F600 Abuse and Neglect to maintain compliance. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. Verification of the facility's education related to the elopement revealed all staff members were educated Licensed Nurses 100 percent (%) of 07/8/2024 received education. Certified Nursing Assistant 100% as of 7/18/ 2024 Dietary 100% as of 7/18/2024 Maintenance 100% as of 7/18/ 2024 Environment 100% as of 7/18/ 2024 Laundry 100% as of 7/18/ 2024 Therapy 100% as of 7/18/ 2024 Department Heads 100% as of 7/18/ 2024 Review of the facility's Policies and Procedures for Abuse, Neglect, Exploitation and Misappropriation effective date 11/30/2014 revised on 11/29/2017 revealed: Policy It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be from abuse, neglect, mistreatment, exploitation and or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free form abuse, neglect, mistreatment, and /or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Neglect: is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include, but are not limited to. Failure to adequately supervise a resident known to wander form the facility without the staff knowledge.

Based on observations, record reviews, and interviews, the facility failed to provide adequate supervision and a secured environment for one (resident #1) out of 4 residents sampled for being at risk of elopement. This facility's deficient practice enabled R#1 to exit the facility undetected by staff on 09/28/2021 at an unknown time after 2:30pm. Resident # 1 has not been found.This situation resulted in immediate jeopardy. The scope and severity was lowered to a (D) as a result of the facility's corrective actions implemented. The immediate jeopardy was determined to be removed on 10/07/2021. Cross reference F 600 & F 835 The findings included: Review of the facility's undated policy and procedure titled, 4.13. Missing Resident revealed: It is the policy of this facility to protect the safety of our residents through early assessment of their risk for exit seeking behaviors. Once identified, we mitigate this flight risk by preparing an individualized care plan in accordance with the policies found in the facility's nursing manual(s). This care plan is reinforced with clear communication among staff, the resident's family and/or representative, volunteers, and other visitors regarding the resident's supervision needs. Review of the facility's undated policy and procedure titled, Elopement of Resident Policy revealed: PROCEDURE: 1. All residents are assessed for potential elopement. 2. Care Plan develop with family and resident participation and updated as needed. 3. Nurse will direct in-house staff to search room to room and all potential areas of the facility: shower rooms, utility rooms, offices, dining rooms, laundry, kitchen, bathrooms, and closets. a. As soon as it is determined that a resident is missing the following will occur: Administrator and Director of Nursing will be notified and report immediately to the facility Contact family/responsible party/physician with all pertinent and update as necessary Administrator and/or Director of Nursing will give direction to contact police. Administrator, Director of Nursing, and police will direct staff activities. Police will be given necessary information regarding resident, including photos and any description necessary . Review of the Face Sheet for R#1 revealed, the admitted [DATE]. Diagnoses included Malignant Neoplasm of lip, Dysphagia, [CONDITION(S)], [CONDITION(S)], Major Depressive disorder, Anxiety disorder, [CONDITION(S)] ([CONDITION(S)]), Latent [CONDITION(S)], Unspecified severe protein-calorie malnutrition, [CONDITION(S)] without lower urinary tract symptoms. Review of R#1's Minimum Data Set (MDS) Admission completed on 05/20/2021 revealed, a score of 14 for the Brief Interview for Mental Status (BIMS). No mood or Behavior were coded. No wandering was coded. He required only supervision for Activities for Daily Living (ADLs), except for dressing and Eating R#1 was independent. His meds included antipsychotic and antidepressant medication. Routinely for 7 days and no special treatments. The Quarterly MDS dated [DATE] revealed a 14 BIMS score. R#1's Mood was coded for little interest or pleasure doing things, no behaviors, and did not wander. R#1 had the same codes for his ADLs functions. The MDS codes for his meds included antipsychotic and antidepressant. Routinely for 7 days and no special treatments. Review of R#1's Physician orders (POs) revealed: On 05/13/2021: [MEDICATION(S)] tab 2mg one tablet by mouth every 12 hours-Diagnosis: [CONDITION(S)] On 05/13/2021 [MEDICATION(S)] tab 20mg ([MEDICATION(S)]) One tablet by mouth once daily-Diagnosis: Depression On 05/13/2021 [MEDICATION(S)] tab 10mg give one tablet by mouth every night at bedtime-Diagnosis: [CONDITION(S)] On 08/13/2021 [MEDICATION(S)] Sol 250/5ML (For [MEDICATION(S)]) Give 10 ml by mouth every 12 hours- Diagnosis: [CONDITION(S)] Review of R#1's most recent Psychiatric Evaluation dated 09/03/2021 revealed, patient with advanced dementia, alert and oriented x1 to x2. Depression, Delusion, Delusion responding well to meds. Diagnosis of [CONDITION(S)], Orders [MEDICATION(S)] and [MEDICATION(S)] evaluated. Review of R#1's Medication Administration Record (MAR) dated on 09/28/2021 revealed R#1 received [MEDICATION(S)] 20mg at 09:00am, and [MEDICATION(S)] 10 mg Q12. Received morning medication but not his night medications ([MEDICATION(S)] 10 mg at 9:00pm). Review of his Medication Administration records indicated he received the medications from September 1 - September 28, 2021 before the elopement. There were no meds scheduled between 09:00am and 09:00pm. Review of R#1's Wander Data Collection Tool dated 05/13/2021 on Admission revealed, the facility checked two answer as Yes (one related to his diagnosis and the other is related to ability to ambulate independently) The scoring is 3 or more Yes is a Definitive Risk and 1-2 a Yes answer is At Risk for Elopement. In the back of the form Interventions included: 4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). (This assessment completed by the facility was not completed as shown on the form presented as an attachment). Under Summary of Findings the BIMS score is blank, and Summary of Findings is blank. (Note the wandering assessment tool completed by facility is not completed as it is not checked whether R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of R#1's Wander Data Collection Tool dated 08/09/2021 revealed, the facility checked 'Yes' for Diagnosis, Independent ambulation and Receiving medication that increased restlessness or agitation. Interventions:4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). This assessment completed by the facility was not completed as shown on the form presented as attachment. Under Summary of Findings the BIMS score is blank, and Summary of Findings stated he is not at wander or elopement risk. (Note the last wandering assessment tool completed by facility is not completed as it is not checked if R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of the Fall Risk assessment dated [DATE], the score was 12 for High Risk. The assessment dated [DATE] score was 8 for low risk. Review of R#1's Nurse Progress Notes dated 09/28/2021 from 07:00am-07:00pm revealed, nurse (Staff A) documented that .between 4:30pm-05:00pm when dinner is on the floor the Certified Nurse Assistant (CNA) notified nurse (Staff A) that resident it is not in the room, at the moment everybody started looking for resident on the floor, another floor, but he is not here in the facility . Review of R#1's Nurse Progress Notes dated 09/28/2021 from7:00pm-07am revealed nurse (Staff B) documented Upon making rounds resident was not found in room. Outgoing nurse reported, resident was not seen as well. A Search party of staff was conducted internally and externally of the facility. DON, police, and guardian notified. Police is conducting investigation, K 9 included. Nearby hospitals were called, description and name of resident was left. They indicated they will follow up with any positive news. Review of R#1's Care Plan dated 05/27/2021 revised on 08/26/2021 revealed, a care plan for Activities. Identified R#1 to be at risk for decreased social interaction/activity/participation related to diagnosis of [CONDITION(S)] and listed his activity preferences such as walk, listen all kind of music, being outside. Care planned for having potential for alteration/has alteration in mood as evidenced by c/o [complaint of] or displays the following: sadness/restlessness/agitated, poor energy and poor interest in doing things Dx. [diagnosis] Depression/ [CONDITION(S)]. Care planned for having a potential for alteration in thought process/Altered thought process related to diagnosis of [CONDITION(S)], periods of forgetfulness and use of [CONDITION(S)] medication. Care Planned for [CONDITION(S)] Drug Use and resident being at risk for side effect related to receiving [CONDITION(S)] medication for the treatment of: Antidepressant for Depression and Antipsychotic for [CONDITION(S)]. Care Planned for being at risk of falls and/or fall related injury related to Poor safety awareness, Side Effect of medication used, Impaired balance, Unsteady gait for his diagnosis of [CONDITION(S)]. Review of R#1's Interdisciplinary Care Plan Conference Record revealed, his [CONDITION(S)] medication regimen was checked as Effective for the use of [MEDICATION(S)] used for [CONDITION(S)] and targeting delusion as specific behavior and use of [MEDICATION(S)] for diagnosis of Depression and targeting the specific behavior of sadness/mood. Review of the List of Residents identified at Elopement Risk provided by the facility on 10/05/2021 at 05:46 pm revealed, four (4) residents were identified at risk for elopement and R#1 was not in that list. During an interview with Registered Nurse (RN)/charge nurse (Staff C) on 10/05/2021 at 08:55 am, staff C revealed last week on 09/28/2021 there was a resident who left the nursing home, and he has not been found yet. Staff C stated R#1 was not in her assignments and R#1 never showed any signs of trying to leave the facility. Staff C stated she believes R#1 got confused and that is why he left the facility. The nurse stated the 4 exit door alarms on the two floors were working perfectly, they were tested , and the alarms went on. Staff C stated she believes R#1 left out one of the doors downstairs, on the first floor. R#1 has scheduled medication for 09:00am and 09:00pm. He received his medication in the morning. Staff C stated the Maintenance Director saw him downstairs when R#1 was getting money from the Bussiness Office. Staff C stated, facility staff realized R#1 was not in the facility by dinner time, they looked for him everywhere and they did not find him. Staff C stated R#1 never showed any elopement signs. Staff C stated the facility's residents did not have bracelets with identification, nor did the facility have pictures of the residents in the charts, and there are no cameras in the facility. Staff C stated nobody saw R#1 leaving and she cannot explain how he left the facility, but she heard the day R#1 left the facility there was a transportation service on the outside of the facility. During an interview with the Maintenance Director on 10/05/2021 at 10:05 am revealed, last Tuesday, 09/28/2021 around 11:00-12:00pm when he was receiving a delivery of supplies, he saw R#1 downstairs on the ground floor/1st floor taking money from the Business Administration office. The Maintenance Director stated, he saw R#1 next to the main door, he had to ask R#1 permission to pass him to go through to the exit door. The Maintenance Director stated there were many people outside waiting for testing, screening and an ambulance was at the front, the ambulance came to pick up someone/another resident, and he did not see anything else. Then he picked up his boxes from outside and went back into the building. The Maintenance Director stated R#1 was inside like 6 feet from the main door. The Maintenance Director stated there is a receptionist, and she is here from 08:30am- 06:00pm. The door is locked, and people have to tell the receptionist to let them leave through the door or press the code to open the door. The Maintenance Director stated the doors are now checked twice every day, morning, and evenings. The Maintenance Director reported, the day R#1 disappeared they checked the doors, and they were working properly. The Maintenance Director stated, the resident was very quiet, he walked slow, he had no idea how the resident left. During an interview with the Corporate Maintenance Supervisor on 10/05/2021 at 10:15 am revealed, the doors are checked twice daily and they were operating well when they checked before and after the resident left the facility. The Corporate Maintenance Supervisor stated, downstairs there are three doors: one in the main lobby, one East exit door and one outside the breakroom. The one in the breakroom does not go outside. The other 2 doors are the only entrances to the facility where people can go in and out, all doors have a keypad. The residents should not know the codes because they change very frequently like once a month or per need, meaning if there is any incident right away, they will change the code. The staff is aware they can't give the code out. The Corporate Maintenance Supervisor stated, there was not an alarm on any of the three doors downstairs, and they did not have the sound feature on in any of those doors. The doors by the staircases on both floors, this included 4 doors, have the sound alarms on, and they worked properly that day when they were tested . The Corporate Maintenance Supervisor stated they are checking all doors twice a day, daily. Interview with the nursing home's owner on 10/05/2021 at 11:15 am revealed, they looked for R#1 everywhere, they are calling hospitals daily and they have not been able to find him. R#1 has no family and Guardianship was notified. The facility's owner revealed, R#1 has a Brief Interview for Mental Status (BIMS) score of 14 (meaning the resident was cognitively intact) and added he looks normal unless he would not take his medication, he might be confused with someone going to [CONDITION(S)]. The resident had a diagnosis of [CONDITION(S)] and that is why he has a legal guardian, but with his medication he was ok. The owner was asked about the facility's practice on putting the name and any other identification on a bracelet as a way to identify the residents, the owner stated, I don't believe this resident who eloped had his bracelet on because he stated, they can take them off once they leave. During a further interview with the owner at 1:50 pm on 10/5/2021 revealed they believe the resident might have been picked up by the transport that was in the facility and is used to take residents out to appointments. During an interview with RN, Staff A on 10/05/2021 at 11:55 am revealed, R#1 was in her assignments. Staff A stated, she did her rounds when she started her shift and he was in his bed sleeping, then she gave R#1 his medication at 09:00am and he was served breakfast. Staff A stated, she observed R#1 was stable and sitting on his bed. Staff A stated R #1 was ambulatory and he used to go around the facility. He never showed any intent of leaving the facility, he was okay going to the smoking area where the smokers were, and thenhe used to come back to the room or go downstairs, but he always came back. Staff A stated, R#1 was not at risk for elopement and explained R#1's Wander assessment was done and did not show any risk for R#1 for wandering and at being risk of elopement. Staff A stated, R#1 wasn't scheduled to receive any medication until 09:00pm. Staff A stated, around dinner time the Certified Nursing Assistant (CNA) looked for R#1 to give him his food and R#1 was not in his room. Staff A stated, she went twice downstairs to look for him and did not find him. Staff A stated, she went to the smoker's area and to the third floor and did not find R#1. Staff A stated, at that point I reported to everyone and everyone from the facility started searching for him. Staff A stated, R#1 was not found and stated, there was no way he could have left the facility by the doors on the 2nd and 3rd floor because they have an alarm system in place, and they would know someone is trying to exit the doors. Staff A stated, she believes R#1 walked by the front door entrance. Staff A stated, she never noticed R#1 wanted to leave the facility. Staff A stated, R#1 was not at risk of elopement or wandering. Staff A stated, someone at the facility saw him receiving money from the office. He was a quiet patient. When asked about the facility's practice on placing a bracelet with identification on the residents' arms, Staff A stated, I am not aware they have to do that .If we would have those bracelets here, I don't you think we as a nurse would put them on?' Staff A stated, this is not something she has been told to do. Staff A stated, she believes R#1 had no bracelet identifying his name. Staff A stated, the facility doesn't keeps pictures for residents in the charts. Staff A stated, the assessments are completed by the admitting nurse or the DON. Staff A stated, she did not complete any assessments on wandering or elopements. The DON was asked about the facility's practice of not using bracelets on the residents to have them identified and she stated on 10/05/2021 at 11:20 am, they should have the bracelet on, but they do not always keep it on .they try to keep them identified sometimes by placing them on the wheelchair. During an interview with the Director of Nursing (DON) on 10/05/2021 at 2:20 pm revealed, the day R#1 eloped from facility there were only two people supposed to be out the only people scheduled were the [CONDITION(S)] patients and they both went to [CONDITION(S)] more or less at the time the resident was seen by the door. The DON stated, she called transportation and they said they only picked up the scheduled residents and no additional passengers. During an interview over the phone with the Receptionist, (Staff D) on 10/05/2021 at 02:25 pm revealed, she only works at nights, and she worked last Tuesday 09/28/2021 from 06:19 pm. Staff D stated, she sees the residents when they come down and come out of the elevator. She reported, no residents are allowed to go outside the facility. Staff D stated, she did not see R#1 after she came to work. Before she started her shift, there was another employee covering the reception area. Staff D stated, the front door are always locked when she is here at work. She does not know R#1 and she has no pictures of him. During an interview with a Certified Nursing Assistant (C N A), (Staff E) on 10/05/2021 at 03:20pm revealed, she was assigned to R#1 during her shift 07:00am-03:00pm. Staff E stated, she learned R#1 eloped after 07:00pm when the DON called her and informed, he was not in the facility. Staff E stated, R#1 was in the facility all day until she last saw him around 2:30 pm. Staff E explained, she did rounds around 06:50am and R#1 was sleeping, then he got his breakfast, and he went back to sleep. At about 10:30am she went back to his room, and he was in his bed, and he was clean and stated he had his shower. He had some food around his mouth, and he washed his mouth. Staff E stated, R#1 was sometimes on the patio or went outside his room for a coffee, but most of the time he was in bed. Staff E stated, R#1 received his meal at lunch time. At one point earlier she saw him going to the patio to smoke. At 2:30 pm R#1 went to the patio for smoking, and she clocked out after 3:00 pm. Staff E stated the other shift came in and nobody complained that R#1 was not there until the DON called her and asked her if R#1 was there and she said, yes. Staff E stated, for R#1 she was checking on him every hour, and explained when passing the rooms, she will always looked and checked whether the residents were in their rooms. Staff E stated, Some residents have bracelet with identification, but she did not remember if he had a bracelet. During an interview with an adminstrative staff member/C N A (Staff F) on 10/05/2021 at 2:45 pm revealed, she was familiar with R#1 and how he looks because she goes to the floor/units at times. Staff F stated, on 09/28/2021 she was covering the receptionist area. Staff F stated the door was closed and she was in charge of opening the door. Staff F stated, whenever she left the reception area to do something she was asked by the DON whether there was another person (either the staff from Corporate's HR (Human Resources) or the Administrator covering the reception area. Staff F stated, they need to input a code to go out of the building, and only staff know the code. If they do not know the code, there is a switch inside the receptionist office and it has to be turned in a locked position any time the door has been unlocked. Staff F reported, nobody can get out unless the switch is unlocked. She reported, staff know the code and they can unlock the door. But they make sure the door remains locked because they did not allow people to get in without screening. Staff F stated, she does not know how R#1 got out of the building and stated she did not see R#1 for the entire day. Staff F stated, she worked from 08:30am to 6:30pm but she stays until like 8:30pm because they were all in the process of searching for the resident. Staff F explained that around 7:00pm when she was about to leave the whole thing started going on from 06:30pm. Staff F stated, she does not know whether R#1 received money that day. Staff reported, from the reception area it is not possible to see the elevators. Staff F stated R#1 was ambulatory and able to walk. Staff F stated, R#1 never showed any intention about leaving the facility. Staff F stated all other entrances to the building have codes and residents can not use those entrances. Staff F stated, the break room has an entrance that is locked and only Maintenance has the key, and there is no way he could have gone through that door. The back door has a keycode too which is different for the main door code. Staff F stated, they went to search for R#1 at the bus stop which is right across from the facility's outside parking, and they did not find R#1. Interview with corporate's HR staff (Staff G) on 10/05/2021 at 02:55 pm revealed, she covered the reception area when Staff F had to leave the reception area to do other things and she did not see R#1. Staff G stated, she was not familiar with R#1 as she only comes to help with the reception area or to assist with staffing. During an interview with C.N.A. (Staff H) on 10/05/2021 at 04:08 pm revealed, when she came, she did her round and she did not see R#1 in bed, he was ambulatory, and he walked all around the building, and he used to go and smoke. Staff H stated, she reported to nurse (Staff A), who asked her to look on the third floor. Staff H stated, at the time coffee was served around from 4:30-05:00pm she did not see R#1 coming to drink his coffee and she reported this to (Staff A) who asked her to go to the smoking area and upstairs to look for him. Staff H stated, she did and did not see R#1 and she reported this to (Staff A). Staff H stated, (Staff A) sent her downstair and R#1 was not found, she went to the vending machine area and did not see R#1. Staff H stated, she went back to nurse (Staff A) and reported. Staff A stated, at that time, she had another patient she had to take care of. Staff H stated, when she finished and started dining, she did not see R#1 and she came back to the nurse (Staff A) and told her, she did not see R#1. Staff H stated, she got assistance from charge nurse (Staff C) to make sure the nurse (Staff A) understood she did not find R#1. Staff H stated, then everyone started looking everywhere like in the bathrooms, outside, all the rooms, room by rooms. Staff H stated, R#1 was ambulatory and able to walk around. Staff H stated, she did not see him trying to exit the facility or voicing that he wanted to leave. Staff H stated, R#1 does not talk too much except for things like can I have a cigarette? Staff H stated, she checks on the residents every two hours. Staff H was asked about R#1 having a bracelet to be identified, Staff H stated, I don't know if the resident had any bracelet with identification or names. Staff H was asked if facility has as a practice/protocol to identify residents via bracelet, she said she will have to look for it. She smiled and stopped answering. During an interview with the Director of Operations (DOO), and the DON on 10/05/2021 at 05:10pm revealed, the DON stated the facility staff called around 7:00pm and they said they could not find R#1. The DON stated, she called all management personnel and they came in and searched the building, some drove around the neighborhood and when they were not able to find R#1, they called Law Enforcement around 9:00pm. The DOO stated, he called R#1's Guardian and left a message in the voicemail, and police arrived sometime around 9:45pm-10:00pm. The police searched the building they brought a K-9 unit, called for support to fly around, drove around and had no success. When they spoke to the Guardian the next morning, he mentioned an address around the city, and she has been looking for possible areas where R#1 might be, but R#1 was not found. The DON stated, R#1's Guardian stated to contact people in the hospital and they are contacting daily and hasn't had success in finding the resident. The DON stated, there was some concern related to R#1 might have gone out for [CONDITION(S)] and they contacted the transportation company, and they had no cooperation. The DOO stated, he met the driver for the transportation's company, and he denied any possibility of having R#1jumping on his bus as they only transport residents with scheduled appointments. The DOO stated, they checked all the exit doors and made sure all were working appropriately, and they were. The DOO stated, they changed the codes, and explained they change the code once monthly by facility standards. The DOO stated, the facility has no cameras which is verified by the DON. The DOO was asked about the resident bracelets they both agreed, bracelets, as soon as you put them on, they take them off. The DOO believes R#1 was alert and oriented enough to memorize the code for the back door and/or he took the opportunity to leave behind someone else. They reported, in the front door there is always someone to supervise that door. The DON stated, she and another employee has been providing relief when the receptionist goes out to lunch. The DOO stated, based on that assumption the front or back side door can be the ones used by R#1. The DOO stated, they are going to have a plastic cover on the back door, and they will have one in the front door and it will be difficult for anyone to observe the keycodes. They already ordered those two covers. They reported, the door in the vending machine room is going to the Daycare and nobody can use that door to get out to the street. They both stated, inservices on Elopement was provided to all staff. During an interview with the DON on 10/05/2021 at 05:42 pm the DON revealed, the facility has procedures in places to monitor other residents identified at risk for elopement and stated they have identified four (4) residents and provided a list of the residents. The DON stated, they have completed the Elopement Risk Assessment, and they have Care Plans for Elopement in place. The DON stated, the facility does not have wander guards in place. The DON stated, they provide supervision by monitoring, engaging them in activities, and getting those residents at risk for elopement busy on meaningful activities. The DON stated, they have family albums with pictures and demographics, etc. The DON stated, R#1 never had those behaviors indicating he was at risk for elopement. R#1 was a loner, his activities were mostly in the patio, and he liked coffee and smoking. The DON stated, smoker residents they stick together to the smoker group and stay together. When asked why there was no Elopement assessment completed for R#1, the DON stated, she did not complete an elopement screen based on the answers the residents got checked when doing the data collection for an evaluation on him to determine the risk of wandering. The DON stated, that even though the answers were 'Yes' to the questions on the tool, she concluded R#1 did not display any behavior indicating he was at risk of elopement, and that is why there is no Elopement Assessment in his chart. Interview via telephone on 10/6/21 at 2:22 PM with the Advanced Practice Registered Nurse (APRN) for R#1's Primary Care Physician (PCP) revealed, the ARNP stated she visits the facility once a week for the past 5 years. The APRN reported, I was notified last Monday or Tuesday night that at dinner time the staff did not see the resident. I received this phone call about 7:30 PM. I went to the facility the next day and I was informed of the facility wide search for the resident. At that time a police detective arrived so I left the staff to speak to the police. When the APRN was asked about her assessment of Resident #1's cognitive status, she stated he was one of those residents that from the outside he seemed perfectly fine but, he suffered from mental illness, [CONDITION(S)]. He was pretty independent in his ADL's, and he was ambulatory. He did need assistance to handle his money, so he had guardian assist for finances. He was living in the facility due to Mental Illness. He was able to make decisions. The APRN was asked if there was any concern that he has been out of the facility now for a week potentially without his antipsychotic medications and she stated, he was not receiving any medications that would cause him physical decompensation, but he has the potential for mental decompensation due to absence of his [CONDITION(S)] medications. Interview with R#1's Psychiatrist via telephone on 10/7/21 at 11:57 AM revealed, R #1 was an elderly man, [AGE] years old with a chronic history of [CONDITION(S)]. Physically he functions well. He walks around and is able to feed himself. He does display some behaviors such as sitting on the floor for no apparent reason. His mental status is always all over the place. He is very disorganized. Cognitively, the problem is that he is [CONDITION(S)] so when you assess him, he does not keep up with what day, month, year etc. it is. The problem is that he is out there somewhere. The Psychiatrist reported, I think he has been missing now for a few days. When asked if he was notified, he stated he received a call a couple days ago. He is out there somewhere and can probably survive. When asked if there was a concern that he had been missing since 9/28/21 and potentially was not taking his antipsychotic and other [CONDITION(S)] medications, he stated the resident was receiving [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. He came to the facility on these medications. The Psychiatrist reported, I have never seen him without the medication so I do not know what his baseline would be without medications. The whole thing is worrisome. He is also a elderly man so walking around for days out there and not being picked up by the police or located at the hospital by the facility is very worrisome. So, where is this man. The Psychatrist reported, My major concern is that this is an elderly man walking around out there with no money, nowhere to go with no access to food or something to drink and the police have still not found him. Related to the Psychiatric Consult dated 9/3/21 which indicated Resident #1 had advanced dementia, was alert and oriented x 1-2 with delusions, he stated his dementia is related to the [CONDITION(S)]. So, when you ask him a simple question he does not answer. His does have cognitive declines that are related to the [CONDITION(S)], but not a true dementia. Again, what worries me most is he is an elderly man out there walking around with nowhere to go and he has still not been found. The facility's immediate jeopardy removal plan was submitted on 10/06/2021. On 10/07/2021, the facility's Immediate Jeopardy Removal Plan was verified by the survey team through observation, record reviews and interviews. The facility's immediate jeopardy removal plan submitted on 10/06/2021 indicated: Residents identified at risk of elopement have name and photo posted at front desk Magnetic door lock codes changed on 9/29/2021. Codes will be changed weekly. 100% of Maintenance staff re-educated on completing daily rather than weekly checks of secure doors and documenting same. Additional audible alarms added to both ground floor exit doors to alert staff of door opening. Facility had 100% of staff complete re-education on verify door locks are engaged, protecting the code, and not sharing the code with others. Facility will install covers over keypads on first floor to hinder any alert and oriented resident from observing the code being utilized. Facility completed a risk assessment on 9/29/2021 to determine likely root cause of resident gaining access to the

Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of 4 residents known to be an elopement risk as evidenced by Resident #1 (R#1) eloped on 09/28/2021 at an unknown time after 2:30 pm undetected, due to the facility's staff failure to fully implement the facility's regular check system. The elopement was not detected until around 5:00pm the same date. This situation resulted in immediate jeopardy. The scope and severity was lowered to a (D) as a result of the facility's corrective actions implemented. The immediate jeopardy was determined to be removed on 10/07/2021. Cross reference F689 & F 835 The findings included: During an interview with Registered Nurse (RN)/charge nurse (Staff C) on 10/05/2021 at 08:55 am, staff C revealed last week on 09/28/2021 there was a resident who left the nursing home, and he has not been found yet. Staff C stated R#1 was not in her assignments and R#1 never showed any signs of trying to leave the facility. Staff C stated she believes R#1 got confused and that is why he left the facility. The nurse stated the 4 exit door alarms on the two floors were working perfectly, they were tested , and the alarms went on. Staff C stated she believes R#1 left out one of the doors downstairs, on the first floor. R#1 has scheduled medication for 09:00am and 09:00pm. He received his medication in the morning. Staff C stated the Maintenance Director saw him downstairs when R#1 was getting money from the Bussiness Office. Staff C stated, facility staff realized R#1 was not in the facility by dinner time, they looked for him everywhere and they did not find him. Staff C stated R#1 never showed any elopement signs. Staff C stated the facility's residents did not have bracelets with identification, nor did the facility have pictures of the residents in the charts, and there are no cameras in the facility. Staff C stated nobody saw R#1 leaving and she cannot explain how he left the facility, but she heard the day R#1 left the facility there was a transportation service on the outside of the facility. During an interview with the Maintenance Director on 10/05/2021 at 10:05 am revealed, last Tuesday, 09/28/2021 around 11:00-12:00pm when he was receiving a delivery of supplies, he saw R#1 downstairs on the ground floor/1st floor taking money from the Business Administration office. The Maintenance Director stated, he saw R#1 next to the main door, he had to ask R#1 permission to pass him to go through to the exit door. The Maintenance Director stated there were many people outside waiting for testing, screening and an ambulance was at the front, the ambulance came to pick up someone/another resident, and he did not see anything else. Then he picked up his boxes from outside and went back into the building. The Maintenance Director stated R#1 was inside like 6 feet from the main door. The Maintenance Director stated there is a receptionist, and she is here from 08:30am- 06:00pm. The door is locked, and people have to tell the receptionist to let them leave through the door or press the code to open the door. The Maintenance Director stated the doors are now checked twice every day, morning, and evenings. The Maintenance Director reported, the day R#1 disappeared they checked the doors, and they were working properly. The Maintenance Director stated, the resident was very quiet, he walked slow, he had no idea how the resident left. During an interview the Corporate Maintenance Supervisor on 10/05/2021 at 10:15 am revealed, the doors are checked twice daily and they were operating well when they checked before and after the resident left the facility. The Corporate Maintenance Supervisor stated, downstairs there are three doors: one in the main lobby, one East exit door and one outside the breakroom. The one in the breakroom does not go outside. The other 2 doors are the only entrances to the facility where people can go in and out, all doors have a keypad. The residents should not know the codes because they change very frequently like once a month or per need, meaning if there is any incident right away, they will change the code. The staff is aware they can't give the code out. The Corporate Maintenance Supervisor stated, there was not an alarm on any of the three doors downstairs, and they did not have the sound feature on in any of those doors. The doors by the staircases on both floors, this included 4 doors, have the sound alarms on, and they worked properly that day when they were tested . The Corpaorate Maintenance Supervisor stated they are checking all doors twice a day, daily. Interview with the nursing home's owner on 10/05/2021 at 11:15 am revealed, they looked for R#1 everywhere, they are calling hospitals daily and they have not been able to find him. R#1 has no family and Guardianship was notified. The facility's owner revealed, R#1 has a Brief Interview for Mental Status (BIMS) score of 14 (meaning the resident was cognitively intact) and added he looks normal unless he would not take his medication, he might be confused with someone going to [CONDITION(S)]. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The owner was asked about the facility's practice on putting the name and any other identification on a bracelet as a way to identify the residents, the owner stated, I don't believe this resident who eloped had his bracelet on because he stated, they can take them off once they leave. During a further interview with the owner at 1:50 pm on 10/5/2021 revealed they believe the resident might have been picked up by the transport that was in the facility and is used to take residents out to appointments. During an interview with RN, Staff A on 10/05/2021 at 11:55 am revealed, R#1 was in her assignments. Staff A stated, she did her rounds when she started her shift and he was in his bed sleeping, then she gave R#1 his medication at 09:00am and he was served breakfast. Staff A stated, she observed R#1 was stable and sitting on his bed. Staff A stated R #1 was ambulatory and he used to go around the facility. He never showed any intent of leaving the facility, he was okay going to the smoking area where the smokers were, and then he used to come back to the room or go downstairs, but he always came back. Staff A stated, R#1 was not at risk for elopement and explained R#1's Wander assessment was done and did not show any risk for R#1 for wandering and at being risk of elopement. Staff A stated, R#1 wasn't scheduled to receive any medication until 09:00pm. Staff A stated, around dinner time the Certified Nursing Assistant (CNA) looked for R#1 to give him his food and R#1 was not in his room. Staff A stated, she went twice downstairs to look for him and did not find him. Staff A stated, she went to the smoker's area and to the third floor and did not find R#1. Staff A stated, at that point I reported to everyone and everyone from the facility started searching for him. Staff A stated, R#1 was not found and stated, there was no way he could have left the facility by the doors on the 2nd and 3rd floor because they have an alarm system in place, and they would know someone is trying to exit the doors. Staff A stated, she believes R#1 walked by the front door entrance. Staff A stated, she never noticed R#1 wanted to leave the facility. Staff A stated, R#1 was not at risk of elopement or wandering. Staff A stated, someone at the facility saw him receiving money from the office. He was a quiet patient. When asked about the facility's practice on placing a bracelet with identification on the residents' arms, Staff A stated, I am not aware they have to do that .If we would have those bracelets here, I don't you think we as a nurse would put them on?' Staff A stated, this is not something she has been told to do. Staff A stated, she believes R#1 had no bracelet identifying his name. Staff A stated, the facility doesn't keeps pictures for residents in the charts. Staff A stated, the assessments are completed by the admitting nurse or the DON. Staff A stated, she did not complete any assessments on wandering or elopements. The DON was asked about the facility's practice of not using bracelets on the residents to have them identified and she stated on 10/05/2021 at 11:20 am, they should have the bracelet on, but they do not always keep it on .they try to keep them identified sometimes by placing them on the wheelchair. During an interview with the Director of Nursing (DON) on 10/05/2021 at 2:20 pm revealed, the day R#1 eloped from facility there were only two people supposed to be out the only people scheduled were the [CONDITION(S)] patients and they both went to [CONDITION(S)] more or less at the time the resident was seen by the door. The DON stated, she called transportation and they said they only picked up the schedule one and no additional passengers. During an interview over the phone with the Receptionist, (Staff D) on 10/05/2021 at 02:25 pm revealed, she only works at nights, and she worked last Tuesday 09/28/2021 from 06:19 pm. Staff D stated, she sees the residents when they come down and come out of the elevator. She reported, no residents are allowed to go outside the facility. Staff D stated, she did not see R#1 after she came to work. Before she started her shift, there was another employee covering the reception area. Staff D stated, the front door are always locked when she is here at work. She does not know R#1 and she has no pictures of him. During an interview with a Certified Nursing Assistant (C N A), (Staff E) on 10/05/2021 at 03:20pm revealed, she was assigned to R#1 during her shift 07:00am-03:00pm. Staff E stated, she learned R#1 eloped after 07:00pm when the DON called her and informed, he was not in the facility. Staff E stated, R#1 was in the facility all day until she last saw him around 2:30 pm. Staff E explained, she did rounds around 06:50am and R#1 was sleeping, then he got his breakfast, and he went back to sleep. At about 10:30am she went back to his room, and he was in his bed, and he was clean and stated he had his shower. He had some food around his mouth, and he washed his mouth. Staff E stated, R#1 was sometimes on the patio or went outside his room for a coffee, but most of the time he was in bed. Staff E stated, R#1 received his meal at lunch time. At one point earlier she saw him going to the patio to smoke. At 2:30 pm R#1 went to the patio for smoking, and she clocked out after 3:00 pm. Staff E stated the other shift came in and nobody complained that R#1 was not there until the DON called her and asked her if R#1 was there and she said, yes. Staff E stated, for R#1 she was checking on him every hour, and explained when passing the rooms, she will always looked and checked whether the residents were in their rooms. Staff E stated, Some residents have bracelet with identification, but she did not remember if he had a bracelet. During an interview with an adminstrative staff member/C NA (Staff F) on 10/05/2021 at 2:45 pm revealed, she was familiar with R#1 and how he looks because she goes to the floor/units at times. Staff F stated, on 09/28/2021 she was covering the receptionist area. Staff F stated the door was closed and she was in charge of opening the door. Staff F stated, whenever she left the reception area to do something she was asked by the DON whether there was another person (either the staff from Corporate's HR (Human Resources) or the Administrator covering the reception area. Staff F stated, they need to input a code to go out of the building, and only staff know the code. If they do not know the code, there is a switch inside the receptionist office and it has to be turned in a locked position any time the door has been unlocked. Staff F reported, nobody can get out unless the switch is unlocked. She reported, staff know the code and they can unlock the door. But they make sure the door remains locked because they did not allow people to get in without screening. Staff F stated, she does not know how R#1 got out of the building and stated she did not see R#1 for the entire day. Staff F stated, she worked from 08:30am to 6:30pm but she stays until like 8:30pm because they were all in the process of searching for the resident. Staff F explained that around 7:00pm when she was about to leave the whole thing started going on from 06:30pm. Staff F stated, she does not know whether R#1 received money that day. Staff reported, from the reception area it is not possible to see the elevators. Staff F stated R#1 was ambulatory and able to walk. Staff F stated, R#1 never showed any intention about leaving the facility. Staff F stated all other entrances to the building have codes and residents can not use those entrances. Staff F stated, the break room has an entrance that is locked and only Maintenance has the key, and there is no way he could have gone through that door. The back door has a keycode too which is different for the main door code. Staff F stated, they went to search for R#1 at the bus stop which is right across from the facility's outside parking, and they did not find R#1. Interview with corporate's HR staff (Staff G) on 10/05/2021 at 02:55 pm revealed, she covered the reception area when Staff F had to leave the reception area to do other things and she did not see R#1. Staff G stated, she was not familiar with R#1 as she only comes to help with the reception area or to assist with staffing. During an interview with C.N.A. (Staff H) on 10/05/2021 at 04:08 pm revealed, when she came, she did her round and she did not see R#1 in bed, he was ambulatory, and he walked all around the building, and he used to go and smoke. Staff H stated, she reported to nurse (Staff A), who asked her to look on the third floor. Staff H stated, at the time coffee was served around from 4:30-05:00pm she did not see R#1 coming to drink his coffee and she reported this to (Staff A) who asked her to go to the smoking area and upstairs to look for him. Staff H stated, she did and did not see R#1 and she reported this to (Staff A). Staff H stated, (Staff A) sent her downstair and R#1 was not found, she went to the vending machine area and did not see R#1. Staff H stated, she went back to nurse (Staff A) and reported. Staff A stated, at that time, she had another patient she had to take care of. Staff H stated, when she finished and started dining, she did not see R#1 and she came back to the nurse (Staff A) and told her, she did not see R#1. Staff H stated, she got assistance from charge nurse (Staff C) to make sure the nurse (Staff A) understood she did not find R#1. Staff H stated, then everyone started looking everywhere like in the bathrooms, outside, all the rooms, room by rooms. Staff H stated, R#1 was ambulatory and able to walk around. Staff H stated, she did not see him trying to exit the facility or voicing that he wanted to leave. Staff H stated, R#1 does not talk too much except for things like can I have a cigarette? Staff H stated, she checks on the residents every two hours. Staff H was asked about R#1 having a bracelet to be identified, Staff H stated, I don't know if the resident had any bracelet with identification or names. Staff H was asked if facility has as a practice/protocol to identify residents via bracelet, she said she will have to look for it. She smiled and stopped answering. During an interview with the Director of Operations (DOO), and the DON on 10/05/2021 at 05:10pm revealed, the DON stated the facility staff called around 7:00pm and they said they could not find R#1. The DON stated, she called all management personnel and they came in and searched the building, some drove around the neighborhood and when they were not able to find R#1, they called Law Enforcement around 9:00pm. The DOO stated, he called R#1's Guardian and left a message in the voicemail, and police arrived sometime around 9:45pm-10:00pm. The police searched the building they brought a K-9 unit, called for support to fly around, drove around and had no success. When they spoke to the Guardian the next morning, he mentioned an address around the city, and she has been looking for possible areas where R#1 might be, but R#1 was not found. The DON stated, R#1's Guardian stated to contact people in the hospital and they are contacting daily and hasn't had success in finding the resident. The DON stated, there was some concern related to R#1 might have gone out for [CONDITION(S)] and they contacted the transportation company, and they had no cooperation. The DOO stated, he met the driver for the transportation's company, and he denied any possibility of having R#1jumping on his bus as they only transport residents with scheduled appointments. The DOO stated, they checked all the exit doors and made sure all were working appropriately, and they were. The DOO stated, they changed the codes, and explained they change the code once monthly by facility standards. The DOO stated, the facility has no cameras which is verified by the DON. The DOO was asked about the resident bracelets they both agreed, bracelets, as soon as you put them on, they take them off. The DOO believes R#1 was alert and oriented enough to memorize the code for the back door and/or he took the opportunity to leave behind someone else. They reported, in the front door there is always someone to supervise that door. The DON stated, she and another employee has been providing relief when the receptionist goes out to lunch. The DOO stated, based on that assumption the front or back side door can be the ones used by R#1. The DOO stated, they are going to have a plastic cover on the back door, and they will have one in the front door and it will be difficult for anyone to observe the keycodes. They already ordered those two covers. They reported, the door in the vending machine room is going to the Daycare and nobody can use that door to get out to the street. They both stated, inservices on Elopement was provided to all staff. During an interview with the DON on 10/05/2021 at 05:42 pm the DON revealed, the facility has procedures in places to monitor other residents identified at risk for elopement and stated they have identified four (4) residents and provided a list of the residents. The DON stated, they have completed the Elopement Risk Assessment, and they have Care Plans for Elopement in place. The DON stated, the facility does not have wander guards in place. The DON stated, they provide supervision by monitoring, engaging them in activities, and getting those residents at risk for elopement busy on meaningful activities. The DON stated, they have family albums with pictures and demographics, etc. The DON stated, R#1 never had those behaviors indicating he was at risk for elopement. R#1 was a loner, his activities were mostly in the patio, and he liked coffee and smoking. The DON stated, smoker residents they stick together to the smoker group and stay together. When asked why there was no Elopement assessment completed for R#1, the DON stated, she did not complete an elopement screen based on the answers the residents got checked when doing the data collection for an evaluation on him to determine the risk of wandering. The DON stated, that even though the answers were 'Yes' to the questions on the tool, she concluded R#1 did not display any behavior indicating he was at risk of elopement, and that is why there is no Elopement Assessment in his chart. Review of the Face Sheet for R#1 revealed, the admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Minimum Data Set (MDS) Admission completed on 05/20/2021 revealed, a score of 14 for the Brief Interview for Mental Status (BIMS). No mood or Behavior were coded. No wandering was coded. He required only supervision for Activities for Daily Living (ADLs), except for dressing and Eating R#1 was independent. His meds included antipsychotic and antidepressant medication. Routinely for 7 days and no special treatments. The Quarterly MDS dated [DATE] revealed a 14 BIMS score. R#1's Mood was coded for little interest or pleasure doing things, no behaviors, and did not wander. R#1 had the same codes for his ADLs functions. The MDS codes for his meds included antipsychotic and antidepressant. Routinely for 7 days and no special treatments. Review of R#1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021: [MEDICATION(S)] tab 2mg one tablet by mouth every 12 hours-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021 [MEDICATION(S)] tab 20mg ([MEDICATION(S)]) One tablet by mouth once daily-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021 [MEDICATION(S)] tab 10mg give one tablet by mouth every night at bedtime-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/13/2021 [MEDICATION(S)] Sol 250/5ML (For [MEDICATION(S)]) Give 10 ml by mouth every 12 hours- Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#1's most recent Psychiatric Evaluation dated 09/03/2021 revealed, patient with advanced dementia, alert and oriented x1 to x2. Depression, Delusion, Delusion responding well to meds. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Received morning medication but not his night medications ([MEDICATION(S)] 10 mg at 9:00pm). There were no meds scheduled between 09:00am and 09:00pm. Review of R#1's Wander Data Collection Tool dated 05/13/2021 on Admission revealed, the facility checked two answers as Yes (one related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the back of the form Interventions included: 4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). (This assessment completed by the facility was not completed as shown on the form presented as an attachment). Under Summary of Findings the BIMS score is blank, and Summary of Findings is blank. (Note the wandering assessment tool completed by the facility is not completed as it is not checked whether R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of R#1's Wander Data Collection Tool dated 08/09/2021 revealed, the facility checked 'Yes' for Diagnosis, Independent ambulation and Receiving medication that increased restlessness or agitation. Interventions:4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). This assessment completed by the facility was not completed as shown on the form presented as an attachment. Under Summary of Findings the BIMS score is blank, and Summary of Findings stated he is not at wander or elopement risk. (Note the last wandering assessment tool completed by facility is not completed as it is not checked if R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of the Fall Risk assessment dated [DATE], the score was 12 for High Risk. The assessment dated [DATE] score was 8 for low risk. Review of R#1's Nurse Progress Notes dated 09/28/2021 from 07:00am-07:00pm revealed, nurse (Staff A) documented that .between 4:30pm-05:00pm when dinner is on the floor the Certified Nurse Assistant (CNA) notified nurse (Staff A) that resident it is not in the room, at the moment everybody started looking for resident on the floor, another floor, but he is not here in the facility . Review of R#1's Nurse Progress Notes dated 09/28/2021 from7:00pm-07am revealed nurse (Staff B) documented Upon making rounds resident was not found in room. Outgoing nurse reported, resident was not seen as well. A Search party of staff was conducted internally and externally of the facility. DON, police, and guardian notified. Police is conducting investigation, K 9 included. Nearby hospitals were called, description and name of resident was left. They indicated they will follow up with and positive news. Review of R#1's Care Plan dated 05/27/2021 revised on 08/26/2021 revealed, a care plan for Activities. Identified R#1 to be at risk for decreased social interaction/activity/participation related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care planned for having potential for alteration/has alteration in mood as evidenced by c/o [complaint of] or displays the following: sadness/restlessness/agitated, poor energy and poor interest in doing things Dx. [diagnosis] Depression/ [CONDITION(S)]. Care planned for having a potential for alteration in thought process/Altered thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Planned for [CONDITION(S)] Drug Use and resident being at risk for side effect related to receiving [CONDITION(S)] medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Planned for being at risk of falls and/or fall related injury related to Poor safety awareness, Side Effect of medication used, Impaired balance, Unsteady gait for his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Interdisciplinary Care Plan Conference Record revealed, his [CONDITION(S)] medication regimen was checked as Effective for the use of [MEDICATION(S)] used for [CONDITION(S)] and targeting delusion as specific behavior and use of [MEDICATION(S)] for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the List of Residents identified at Elopement Risk provided by the facility on 10/05/2021 at 05:46 pm revealed, only four (4) residents were identified at risk for elopement and R#1 was not in that list. Review of the List of Residents identified at Elopement Risk provided by facility on 10/07/2021 after the facility was presented with the Immediate Jeopardy (IJ) templates and the facility's Removal of IJ Plan was provided revealed, there were twenty-two (22) residents identified at risk for elopement. An additional 18 residents were added to the list of residents at risk for elopement. Interview via telephone on 10/6/21 at 2:22 PM with the Advanced Practice Registered Nurse (APRN) for R#1's Primary Care Physician (PCP) revealed, the ARNP stated she visits the facility once a week for the past 5 years. I was notified last Monday or Tuesday night that at dinner time the staff did not see the resident. I received this phone call about 7:30 PM. The APRN reported, I went to the facility the next day and I was informed of the facility wide search for the resident. At that time a police detective arrived so I left the staff to speak to the police. When the APRN was asked about her assessment of Resident #1's cognitive status, she stated he was one of those residents that from the outside he seemed perfectly fine but, he suffered from mental illness, [CONDITION(S)]. He was pretty independent in his ADL's, and he was ambulatory. He did need assistance to handle his money, so he had guardian assist for finances. He was living in the facility due to Mental Illness. He was able to make decisions. The APRN was asked if there was any concern that he has been out of the facility now for a week potentially without his antipsychotic medications and she stated, he was not receiving any medications that would cause him physical decompensation, but he has the potential for mental decompensation due to absence of his [CONDITION(S)] medications. Interview with R#1's Psychiatrist via telephone on 10/7/21 at 11:57 AM revealed, R #1 was an elderly man, [AGE] years old with a chronic history of [CONDITION(S)]. Physically he functions well. He walks around and is able to feed himself. He does display some behaviors such as sitting on the floor for no apparent reason. His mental status is always all over the place. He is very disorganized. Cognitively, the problem is that he is [CONDITION(S)] so when you assess him, he does not keep up with what day, month, year etc. it is. The problem is that he is out there somewhere. The Psychiatrist reported, I think he has been missing now for a few days. When asked if he was notified, he stated he received a call a couple days ago. He is out there somewhere and can probably survive. When asked if there was a concern that he had been missing since 9/28/21 and potentially was not taking his antipsychotic and other [CONDITION(S)] medications, he stated the resident was receiving [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. He came to the facility on these medications. The Psychiatrist reported, I have never seen him without the medication so I do not know what his baseline would be without medications. The whole thing is worrisome. He is also a elderly man so walking around for days out there and not being picked up by the police or located at the hospital by the facility is very worrisome. So, where is this man. The Psychiatrist reported, My major concern is that this is an elderly man walking around out there with no money, nowhere to go with no access to food or something to drink and the police have still not found him. Related to the Psychiatric Consult dated 9/3/21 which indicated Resident #1 had advanced dementia, was alert and oriented x 1-2 with delusions, he stated his dementia is related to the [CONDITION(S)]. So, when you ask him a simple question he does not answer. His does have cognitive declines that are related to the [CONDITION(S)], but not a true dementia. Again, what worries me most is he is an elderly man out there walking around with nowhere to go and he has still not been found. The facility's immediate jeopardy removal plan was submitted on 10/06/2021. On 10/07/2021, the facility's Immediate Jeopardy Removal Plan was verified by the survey team through observation, record reviews and interviews. The facility's immediate jeopardy removal plan submitted on 10/06/2021 indicated: Residents identified at risk of elopement have name and photo posted at front desk Magnetic door lock codes changed on 9/29/2021. Codes will be changed weekly. 100% of Maintenance staff re-educated on completing daily rather than weekly checks of secure doors and documenting same. Additional audible alarms added to both ground floor exit doors to alert staff of door opening. Facility had 100% of staff complete re-education on verify door locks are engaged, protecting the code, and not sharing the code with others. Facility will install covers over keypads on first floor to hinder any alert and oriented resident from observing the code being utilized. Facility completed a risk assessment on 9/29/2021 to determine likely root cause of resident gaining access to the exterior. Determined that in all likelihood resident was allowed to exit with transportation company that was at facility around the last time resident was seen. Facility will educate third party transportation providers on ensuring door closes behind them before walking away from door. Facility re-educated housekeeping and maintenance staff on only utilizing front door to take trash to dumpster area in rear of building, rather than side door that is closer to dumpster. 100% of all residents re-assessed for elopement on 9/29/2021. Resident Council emergency meeting held on 9/29/2021 to re-educate residents on proper discharge planning, leaves of absence or AMA [Against Medical Advice] discharges. Re-educated 100% of staff on missing residents, elopement, routine checks of residents and proper monitoring of residents. QAPI meeting held on 9/29/2021 to address concerns. Staff education on elopement and missing residents increased from semi-annually to quarterly and upon hire. Staff re-educated on contacting the police immediately upon believing a resident is missing rather than after conducting a facility search even th

Based on observations, record reviews and interviews, the facility's administration failed to implement, provide, and ensure that effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of 4 sampled residents who were at risk of elopement. As evidenced by inadequate safety measures that included an ineffective wander alert system, failure to ensure exit door alarms were audible in all areas of the facility in the event of an emergency and failure by staff to provide and implement specific instructions for R #1 who eloped undetected. These deficient practices enabled R #1 to exit the facility undetected on 09/28/2021 at an unknown time after 2:30pm through an un-identified exit door placing the resident at risk for seriousharm, injury or death. This situation resulted in immediate jeopardy. The scope and severity was lowered to a (D) as a result of the facility's corrective actions implemented. The immediate jeopardy was determined to be removed on 10/07/2021. Cross references F 600 & F 689 The findings included: Review of the undated job description for the job titled, Administrator revealed: Purpose of Your Job Position: The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities: Administrative Functions -Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issues by the governing board. -Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. - Assist the HR [Human Resources] Director and department directors in the development of performance-based job evaluations. -Establish rapport in and among departments so that each can realize the importance of teamwork. -Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Review of the undated job description for the job titled, Director of Nursing Services revealed: Purpose of Your Job Position: The primary purpose pf your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Administrative Functions -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 nursing care facilities. -Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing services department. -Maintain a reference library of written nursing material (i.e., PDR'S [Physicians Desk Reference], Regulations, Standards of Practice, etc.) that will assist the nursing service department in meeting the day-to-day needs of resident. -Develop, maintain, and periodically update the Nursing Service Procedures Manual and nursing service objectives and philosophies. -Develop and implement a nursing service organization structure. Make written and oral reports/recommendations to the Administrator, as necessary/required, concerning the operation of the nursing service department. Review of the undated job description for the job titled, Charge Nurse revealed: Purpose of Your Job Position: The primary purpose of your job is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Administrative Functions -Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. -Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. -Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities. -Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility. -Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. -Make written and oral reports/recommendations concerning the activities of your shift as required. Review of the undated job description for the job titled, Registered Nurse/Licensed Practical Nurse revealed: Purpose of Your Job Position: The primary purpose of your job is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Administrative Functions Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. -Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. -Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities. -Make written and oral reports/recommendations concerning the activities of your shift as required. Review of the undated job description for the job titled, Certified Nursing Assistant revealed: Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. Duties and Responsibilities: Administrative Functions -Use of wristband or photo card file to identify residents before administering treatments, serving meals, etc. as necessary -Record all entries on flow sheets, notes, charts, etc. in an informative and descriptive manner. -Use only authorized abbreviations established by this facility when recording information. -Report al changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical. -Report all accidents and incidents you observe on the shift that they occur. -Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator. -Agree not to disclose resident's protected health information abd promptly report suspected or known violations of such disclosure to the Administrator. -Report any known or suspected unauthorized attempt to access facility's information system. Review of the facility's policy and procedures titled, Allegation of Abuse and Neglect Worksheet (undated) revealed: Neglect as Failure to provide good or services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's undated policy and procedure titled, 4.13. Missing Resident revealed: It is the policy of this facility to protect the safety of our residents through early assessment of their risk for exit seeking behaviors. Once identified, we mitigate this flight risk by preparing an individualized care plan in accordance with the policies found in the facility's nursing manual(s). This care plan is reinforced with clear communication among staff, the resident's family and/or representative, volunteers, and other visitors regarding the resident's supervision needs. Review of the facility's undated policy and procedure titled, Elopement of Resident Policy revealed: PROCEDURE: 1. All residents are assessed for potential elopement. 2. Care Plan develop with family and resident participation and updated as needed. 3. Nurse will direct in-house staff to search room to room and all potential areas of the facility: shower rooms, utility rooms, offices, dining rooms, laundry, kitchen, bathrooms, and closets. a. As soon as it is determined that a resident is missing the following will occur: Administrator and Director of Nursing will be notified and report immediately to the facility Contact family/responsible party/physician with all pertinent and update as necessary Administrator and/or Director of Nursing will give direction to contact police. Administrator, Director of Nursing, and police will direct staff activities. Police will be given necessary information regarding resident, including photos and any description necessary . Review of the Face Sheet for R#1 revealed, the admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Minimum Data Set (MDS) Admission completed on 05/20/2021 revealed, a score of 14 for the Brief Interview for Mental Status (BIMS). No mood or Behavior were coded. No wandering was coded. He required only supervision for Activities for Daily Living (ADLs), except for dressing and Eating R#1 was independent. His meds included antipsychotic and antidepressant medication. Routinely for 7 days and no special treatments. The Quarterly MDS dated [DATE] revealed a 14 BIMS score. R#1's Mood was coded for little interest or pleasure doing things, no behaviors, and did not wander. R#1 had the same codes for his ADLs functions. The MDS codes for his meds included antipsychotic and antidepressant. Routinely for 7 days and no special treatments. Review of R#1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021: [MEDICATION(S)] tab 2mg one tablet by mouth every 12 hours-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021 [MEDICATION(S)] tab 20mg ([MEDICATION(S)]) One tablet by mouth once daily-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/13/2021 [MEDICATION(S)] tab 10mg give one tablet by mouth every night at bedtime-Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/13/2021 [MEDICATION(S)] Sol 250/5ML (For [MEDICATION(S)]) Give 10 ml by mouth every 12 hours- Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#1's most recent Psychiatric Evaluation dated 09/03/2021 revealed, patient with advanced dementia, alert and oriented x1 to x2. Depression, Delusion, Delusion responding well to meds. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Received morning medication but not his night medications ([MEDICATION(S)] 10 mg at 9:00pm). Review of his records indicated he received the medications days before the elopement. There were no meds scheduled between 09:00am and 09:00pm. Review of R#1's Wander Data Collection Tool dated 05/13/2021 on Admission revealed, the facility checked two answer as Yes (one related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the back of the form Interventions included: 4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). (This assessment completed by the facility was not completed as shown on the form presented as an attachment). Under Summary of Findings the BIMS score is blank, and Summary of Findings is blank. (Note the wandering assessment tool completed by facility is not completed as it is not checked whether R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of R#1's Wander Data Collection Tool dated 08/09/2021 revealed, the facility checked 'Yes' for Diagnosis, Independent ambulation and Receiving medication that increased restlessness or agitation. Interventions:4 (Frequent monitoring Check every 2 hours), 6 (identification bracelet), and 12 (Personalization of room with familiar objects and photos). This assessment completed by the facility was not completed as shown on the form presented as attachment. Under Summary of Findings the BIMS score is blank, and Summary of Findings stated he is not at wander or elopement risk. (Note the last wandering assessment tool completed by facility is not completed as it is not checked if R#1 is Definitive Risk or at risk for Elopement or not at risk). Review of the Fall Risk assessment dated [DATE], the score was 12 for High Risk. The assessment dated [DATE] score was 8 for low risk. Review of R#1's Nurse Progress Notes dated 09/28/2021 from 07:00am-07:00pm revealed, nurse (Staff A) documented that .between 4:30pm-05:00pm when dinner is on the floor the Certified Nurse Assistant (CNA) notified nurse (Staff A) that resident it is not in the room, at the moment everybody started looking for resident on the floor, another floor, but he is not here in the facility . Review of R#1's Nurse Progress Notes dated 09/28/2021 from7:00pm-07am revealed nurse (Staff B) documented Upon making rounds resident was not found in room. Outgoing nurse reported, resident was not seen as well. A Search party of staff was conducted internally and externally of the facility. DON, police, and guardian notified. Police is conducting investigation, K 9 included. Nearby hospitals were called, description and name of resident was left. They indicated they will follow up with any positive news. Review of R#1's Care Plan dated 05/27/2021 revised on 08/26/2021 revealed, a care plan for Activities. Identified R#1 to be at risk for decreased social interaction/activity/participation related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care planned for having potential for alteration/has alteration in mood as evidenced by c/o [complaint of] or displays the following: sadness/restlessness/agitated, poor energy and poor interest in doing things Dx. [diagnosis] Depression/ [CONDITION(S)]. Care planned for having a potential for alteration in thought process/Altered thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Planned for [CONDITION(S)] Drug Use and resident being at risk for side effect related to receiving [CONDITION(S)] medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Planned for being at risk of falls and/or fall related injury related to Poor safety awareness, Side Effect of medication used, Impaired balance, Unsteady gait for his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's Interdisciplinary Care Plan Conference Record revealed, his [CONDITION(S)] medication regimen was checked as Effective for the use of [MEDICATION(S)] used for [CONDITION(S)] and targeting delusion as specific behavior and use of [MEDICATION(S)] for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility abuse/neglect log revealed, the incident was not reported to the state agency as neglect. An AHCA (Agency for Healthcare Administration) Federal Immediate and Five-Day Reports were not submitted by the facility. Review of the List of Residents identified at Elopement Risk provided by the facility on 10/05/2021 at 05:46 pm revealed, only four (4) residents were identified at risk for elopement and R#1 was not in that list. During an interview with Registered Nurse (RN)/charge nurse (Staff C) on 10/05/2021 at 08:55 am, staff C revealed last week on 09/28/2021 there was a resident who left the nursing home, and he has not been found yet. Staff C stated R#1 was not in her assignments and R#1 never showed any signs of trying to leave the facility. Staff C stated she believes R#1 got confused and that is why he left the facility. The nurse stated the 4 exit door alarms on the two floors were working perfectly, they were tested , and the alarms went on. Staff C stated she believes R#1 left out one of the doors downstairs, on the first floor. R#1 has scheduled medication for 09:00am and 09:00pm. He received his medication in the morning. Staff C stated the Maintenance Director saw him downstairs when R#1 was getting money from the Bussiness Office. Staff C stated, facility staff realized R#1 was not in the facility by dinner time, they looked for him everywhere and they did not find him. Staff C stated R#1 never showed any elopement signs. Staff C stated the facility's residents did not have bracelets with identification, nor did the facility have pictures of the residents in the charts, and there are no cameras in the facility. Staff C stated nobody saw R#1 leaving and she cannot explain how he left the facility, but she heard the day R#1 left the facility there was a transportation service on the outside of the facility. During an interview with the Maintenance Director on 10/05/2021 at 10:05 am revealed, last Tuesday, 09/28/2021 around 11:00-12:00pm when he was receiving a delivery of supplies, he saw R#1 downstairs on the ground floor/1st floor taking money from the Business Administration office. The Maintenance Director stated, he saw R#1 next to the main door, he had to ask R#1 permission to pass him to go through to the exit door. The Maintenance Director stated there were many people outside waiting for testing, screening and an ambulance was at the front, the ambulance came to pick up someone/another resident, and he did not see anything else. Then he picked up his boxes from outside and went back into the building. The Maintenance Director stated R#1 was inside like 6 feet from the main door. The Maintenance Director stated there is a receptionist, and she is here from 08:30am- 06:00pm. The door is locked, and people have to tell the receptionist to let them leave through the door or press the code to open the door. The Maintenance Director stated the doors are now checked twice every day, morning, and evenings. The Maintenance Director reported, the day R#1 disappeared they checked the doors, and they were working properly. The Maintenance Director stated, the resident was very quiet, he walked slow, he had no idea how the resident left. During an interview with the Corporate Maintenance Supervisor on 10/05/2021 at 10:15 am revealed, the doors are checked twice daily and they were operating well when they checked before and after the resident left the facility. The Corporate Maintenance Supervisor stated, downstairs there are three doors: one in the main lobby, one East exit door and one outside the breakroom. The one in the breakroom does not go outside. The other 2 doors are the only entrances to the facility where people can go in and out, all doors have a keypad. The residents should not know the codes because they change very frequently like once a month or per need, meaning if there is any incident right away, they will change the code. The staff is aware they can't give the code out. The Corporate Maintenance Supervisor stated, there was not an alarm on any of the three doors downstairs, and they did not have the sound feature on in any of those doors. The doors by the staircases on both floors, this included 4 doors, have the sound alarms on, and they worked properly that day when they were tested . The Corporate Maintenance Supervisor stated they are checking all doors twice a day, daily. Interview with the nursing home's owner on 10/05/2021 at 11:15 am revealed, they looked for R#1 everywhere, they are calling hospitals daily and they have not been able to find him. R#1 has no family and Guardianship was notified. The facility's owner revealed, R#1 has a Brief Interview for Mental Status (BIMS) score of 14 (meaning the resident was cognitively intact) and added he looks normal unless he would not take his medication, he might be confused with someone going to [CONDITION(S)]. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The owner was asked about the facility's practice on putting the name and any other identification on a bracelet as a way to identify the residents, the owner stated, I don't believe this resident who eloped had his bracelet on because he stated, they can take them off once they leave. During a further interview with the owner at 1:50 pm on 10/5/2021 revealed they believe the resident might have been picked up by the transport that was in the facility and is used to take residents out to appointments. During an interview with RN, Staff A on 10/05/2021 at 11:55 am revealed, R#1 was in her assignments. Staff A stated, she did her rounds when she started her shift and he was in his bed sleeping, then she gave R#1 his medication at 09:00am and he was served breakfast. Staff A stated, she observed R#1 was stable and sitting on his bed. Staff A stated R #1 was ambulatory and he used to go around the facility. He never showed any intent of leaving the facility, he was okay going to the smoking area where the smokers were, and thenhe used to come back to the room or go downstairs, but he always came back. Staff A stated, R#1 was not at risk for elopement and explained R#1's Wander assessment was done and did not show any risk for R#1 for wandering and at being risk of elopement. Staff A stated, R#1 wasn't scheduled to receive any medication until 09:00pm. Staff A stated, around dinner time the Certified Nursing Assistant (CNA) looked for R#1 to give him his food and R#1 was not in his room. Staff A stated, she went twice downstairs to look for him and did not find him. Staff A stated, she went to the smoker's area and to the third floor and did not find R#1. Staff A stated, at that point I reported to everyone and everyone from the facility started searching for him. Staff A stated, R#1 was not found and stated, there was no way he could have left the facility by the doors on the 2nd and 3rd floor because they have an alarm system in place, and they would know someone is trying to exit the doors. Staff A stated, she believes R#1 walked by the front door entrance. Staff A stated, she never noticed R#1 wanted to leave the facility. Staff A stated, R#1 was not at risk of elopement or wandering. Staff A stated, someone at the facility saw him receiving money from the office. He was a quiet patient. When asked about the facility's practice on placing a bracelet with identification on the residents' arms, Staff A stated, I am not aware they have to do that .If we would have those bracelets here, I don't you think we as a nurse would put them on?' Staff A stated, this is not something she has been told to do. Staff A stated, she believes R#1 had no bracelet identifying his name. Staff A stated, the facility doesn't keeps pictures for residents in the charts. Staff A stated, the assessments are completed by the admitting nurse or the DON. Staff A stated, she did not complete any assessments on wandering or elopements. The DON was asked about the facility's practice of not using bracelets on the residents to have them identified and she stated on 10/05/2021 at 11:20 am, they should have the bracelet on, but they do not always keep it on .they try to keep them identified sometimes by placing them on the wheelchair. During an interview with the Director of Nursing (DON) on 10/05/2021 at 2:20 pm revealed, the day R#1 eloped from facility there were only two people supposed to be out the only people scheduled were the [CONDITION(S)] patients and they both went to [CONDITION(S)] more or less at the time the resident was seen by the door. The DON stated, she called transportation and they said they only picked up the schedule one and no additional passengers. During an interview over the phone with the Receptionist, (Staff D) on 10/05/2021 at 02:25 pm revealed, she only works at nights, and she worked last Tuesday 09/28/2021 from 06:19 pm. Staff D stated, she sees the residents when they come down and come out of the elevator. She reported, no residents are allowed to go outside the facility. Staff D stated, she did not see R#1 after she came to work. Before she started her shift, there was another employee covering the reception area. Staff D stated, the front door are always locked when she is here at work. She does not know R#1 and she has no pictures of him. During an interview with a Certified Nursing Assistant (C N A), (Staff E) on 10/05/2021 at 03:20pm revealed, she was assigned to R#1 during her shift 07:00am-03:00pm. Staff E stated, she learned R#1 eloped after 07:00pm when the DON called her and informed, he was not in the facility. Staff E stated, R#1 was in the facility all day until she last saw him around 2:30 pm. Staff E explained, she did rounds around 06:50am and R#1 was sleeping, then he got his breakfast, and he went back to sleep. At about 10:30am she went back to his room, and he was in his bed, and he was clean and stated he had his shower. He had some food around his mouth, and he washed his mouth. Staff E stated, R#1 was sometimes on the patio or went outside his room for a coffee, but most of the time he was in bed. Staff E stated, R#1 received his meal at lunch time. At one point earlier she saw him going to the patio to smoke. At 2:30 pm R#1 went to the patio for smoking, and she clocked out after 3:00 pm. Staff E stated the other shift came in and nobody complained that R#1 was not there until the DON called her and asked her if R#1 was there and she said, yes. Staff E stated, for R#1 she was checking on him every hour, and explained when passing the rooms, she will always looked and checked whether the residents were in their rooms. Staff E stated, Some residents have bracelet with identification, but she did not remember if he had a bracelet. During an interview with an adminstrative staff member/C N A (Staff F) on 10/05/2021 at 2:45 pm revealed, she was familiar with R#1 and how he looks because she goes to the floor/units at times. Staff F stated, on 09/28/2021 she was covering the receptionist area. Staff F stated the door was closed and she was in charge of opening the door. Staff F stated, whenever she left the reception area to do something she was asked by the DON whether there was another person (either the staff from Corporate's HR (Human Resources) or the Administrator covering the reception area. Staff F stated, they need to input a code to go out of the building, and only staff know the code. If they do not know the code, there is a switch inside the receptionist office and it has to be turned in a locked position any time the door has been unlocked. Staff F reported, nobody can get out unless the switch is unlocked. She reported, staff know the code and they can unlock the door. But they make sure the door remains locked because they did not allow people to get in without screening. Staff F stated, she does not know how R#1 got out of the building and stated she did not see R#1 for the entire day. Staff F stated, she worked from 08:30am to 6:30pm but she stays until like 8:30pm because they were all in the process of searching for the resident. Staff F explained that around 7:00pm when she was about to leave the whole thing started going on from 06:30pm. Staff F stated, she does not know whether R#1 received money that day. Staff reported, from the reception area it is not possible to see the elevators. Staff F stated R#1 was ambulatory and able to walk. Staff F stated, R#1 never showed any intention about leaving the facility. Staff F stated all other entrances to the building have codes and residents can not use those entrances. Staff F stated, the break room has an entrance that is locked and only Maintenance has the key, and there is no way he could have gone through that door. The back door has a keycode too which is different for the main door code. Staff F stated, they went to search for R#1 at the bus stop which is right across from the facility's outside parking, and they did not find R#1. Interview with corporate's HR staff (Staff G) on 10/05/2021 at 02:55 pm revealed, she covered the reception area when Staff F had to leave the reception area to do other things and she did not see R#1. Staff G stated, she was not familiar with R#1 as she only comes to help with the reception area or to assist with staffing. During an interview with C.N.A. (Staff H) on 10/05/2021 at 04:08 pm revealed, when she came, she did her round and she did not see R#1 in bed, he was ambulatory, and he walked all around the building, and he used to go and smoke. Staff H stated, she reported to nurse (Staff A), who asked her to look on the third floor. Staff H stated, at the time coffee was served around from 4:30-05:00pm she did not see R#1 coming to drink his coffee and she reported this to (Staff A) who asked her to go to the smoking area and upstairs to look for him. Staff H stated, she did and did not see R#1 and she reported this to (Staff A). Staff H stated, (Staff A) sent her downstair and R#1 was not found, she went to the vending machine area and did not see R#1. Staff H stated, she went back to nurse (Staff A) and reported. Staff A stated, at that time, she had another patient she had to take care of. Staff H stated, when she finished and started dining, she did not see R#1 and she came back to the nurse (Staff A) and told her, she did not see R#1. Staff H stated, she got assistance from charge nurse (Staff C) to make sure the nurse (Staff A) understood she did not find R#1. Staff H stated, then everyone started looking everywhere like in the bathrooms, outside, all the rooms, room by rooms. Staff H stated, R#1 was ambulatory and able to walk around. Staff H stated, she did not see him trying to exit the facility or voicing that he wanted to leave. Staff H stated, R#1 does not talk too much except for things like can I have a cigarette? Staff H stated, she checks on the residents every two hours. Staff H was asked about R#1 having a bracelet to be identified, Staff H stated, I don't know if the resident had any bracelet with identification or names. Staff H was asked if facility has as a practice/protocol to identify residents via bracelet, she said she will have to look for it. She smiled and stopped answering. During an interview with the Director of Operations (DOO), and the DON on 10/05/2021 at 05:10pm revealed, the DON stated the facility staff called around 7:00pm and they said they could not find R#1. The DON stated, she called all management personnel and they came in and searched the building, some drove around the neighborhood and when they were not able to find R#1, they called Law Enforcement around 9:00pm. The DOO stated, he called R#1's Guardian and left a message in the voicemail, and police arrived sometime around 9:45pm-10:00pm. The police searched the building they brought a K-9 unit, called for support to fly around, drove around and had no success. When they spoke to the Guardian the next morning, he mentioned an address around the city, and she has been looking for possible areas where R#1 might be, but R#1 was not found.

Based on observation, record review,, and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 29 stage 2 sample residents (#125 and #66). This affected resident #125 as it related to failure to ensure effective pain management and coordination of services with hospice, and resident #66 as it related to failure to adequately coordinate care within the staff within the facility and with the contracted home [MEDICAL TREATMENT] services related to fluid restriction/maintenance, and weight assessment and management. The findings include: Observation and interview on 12/16/11 at 11:10 am with resident #125 in his room was observed clean and well groomed and packing a bag to go out on pass; surveyor requested a few minutes of his time and resident #125 stated it was okay to ask him a few questions. At this time surveyor proceeded to ask resident how his day was going so far and he said okay. Surveyor noticed the left side of resident #125 face looked a little bigger than the right side and asked resident #125 if his face was swollen and if his face hurts. Resident #125 proceeded to touch his face and stated; he had [MEDICAL CONDITION] therapy and he has [MEDICAL CONDITION]. At this time surveyor asked resident #125 if he is in pain and he stated " yes " . Surveyor asked resident if he got medication for the pain and he stated that he wears a patch but he still gets breakthrough pain. At this time he stated he also has pain in left leg and proceeded to lift his pants leg up. Surveyor then asked resident if wears ted hose because at this time only his socks were showing. Resident #125 raised his pants up to his knee where the surveyor observed the socks over his ted hose. He also stated it took a long time before he got his stockings because there is a communication problem between the facility and hospice. Resident #125 also stated," the pain medication does not work like it should; I wish there is something else I can get." Record review of resident #125 face sheet revealed he was admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of resident #125 initial Minimum Data Set ((MDS) dated [DATE] revealed resident #125 is alert and oriented times three. He has no behavior issues and he is independent with bed mobility, dressing, and bathing. Further record review of resident #125 MDS section J revealed he is on a scheduled pain medication regimen as well as receiving pain medication on as needed (PRN) basis. According to section J during a Pain Assessment Interview with resident #125 when asked: -Have you had pain or hurting at any time in the last 5 day? He replied yes. -How much of the time have your experienced pain or hurting over the last 5 days? He replied almost constantly. -Over the past 5 days, has pain made it hard for you to sleep at night? He replied no. -Over the past 5 days have you limited your day to day activities because of pain? He replied no. -When asked to rate the intensity of worst pain he had in the last 5 days? He replied very severe. Record review of resident #125 care plan reveals he has a terminal prognosis: potential for grief, withdrawal, depression, or anxiety. He has a goal for comfort to be maintained. The approaches to reach these goals includes but not limited to: -Consult with the physician and Social Services to have Hospice care for resident in the facility. -Observe resident closely for signs of pain, administer pain medications as order and notify the physician immediately if there is pain breakthrough. -Work cooperatively with Hospice to meet resident needs. -Work with nursing staff to provide maximum comfort for the resident. Record review of resident #125 Admission Assessment Data Collection Form on admission 11/3/11 revealed resident experience pain in the last 7 days with an intensity between 9-10 of sharp burning pain in his mouth. He also stated medication makes the pain feel better and when the medication is wearing off the pain feels worst. Record review of resident #125 Admission Assessment Data Collection Form on admission 11/10/11 also revealed that the resident experienced pain in the last 7 days with an intensity of a 6 of dull stinging pain in his mouth. He also stated medication makes the pain feel better and when the medication is wearing off the pain feels worst. Record review of resident #125 nurse ' s notes on 11/5/11 revealed a call was placed to pharmacy regarding [MEDICATION NAME] and staff spoke to a representative that stated delay was due to a lack of prescription processing. Resident states "I am always in pain everything hurts " resident rates his pain intensity at 7 out of 10. Record review of resident #125 medication administration record (MAR) on 11/4/11 revealed it was circled with no documentation on the back of the MAR why he did not get his [MEDICATION NAME] patch 100mcg/hr and [MEDICATION NAME] 50mg (milligrams) PRN was not administered until 11/6/11. Record review of resident #125 Quality Care Notes on 12/1/11 revealed that the resident stated that the " pain patch is not working " . . Record review of resident #125 Physician Order Sheets for November and December 2011 revealed resident #125 receives [MEDICATION NAME] 100 micrograms per hour (mcg/hr.) patch every 72 hours (hr) for pain. Record review of resident #125 November 2011 monitoring sheet for pain located in clinical record revealed he was administered [MEDICATION NAME] 50mg on 11/6/11 at 1pm for pain in his throat with score of 6 out of 10 and nurse assessed the resident having a tense body and 1 hour after pain medication was administered the score was 0 out of 10 for pain. Record review of resident #125 December 2011 monitoring sheet for pain located with current MAR revealed no monitoring is being done and pain sheet was blank. Interview with the Clinical Care Manager on 12/16/11 at 10:34am confirmed prior to giving surveyor blank empty pain sheet stated the staff was monitoring the resident #125 for pain. Surveyor requested documentation for the monitoring and the sheet was blank. The Clinical manager stated I am shocked too " it is what it is " I do not know why it ' s blank. After the interview with Clinical Nurse Manager; she went to the LPN who went to resident #125 at 11:20am to assess him for pain in his throat and documented on the pain sheet tense body with intensity of 8 out 10 scale; unable to assess one hour later because resident went out on pass. Record review of resident clinical record revealed on 11/4/11, 12/7/11 and 12/12/11 resident #125 has a script for [MEDICATION NAME] 100mcg every 72 hr for pain with a count of 10 patches. Record review of resident #125 MAR December 2011 revealed he did not get his [MEDICATION NAME] 100 mcg/hr on 12/5/11 because it was not available by the pharmacy. Record review of resident #125 physician orders dated 12/14/11 revealed [MEDICATION NAME] 50 milligram (mg) every 6 hours as needed for pain. Interview on 12/16/11 at 11:19am with the LPN stated resident #125 is alert and oriented times 3 and he never really told of any pain in his left leg or throat and stated he has a patch and she do not document if pain medication is effective or not. Record review of resident #125 MDS dated [DATE] section J1400 revealed has a condition or chronic disease that may result in a life expectancy of less than 6 months. He is also coded for Hospice services. Record review of resident #125 care plan reveals he is at risk for alteration in comfort. Resident #125 has a goal to maintain current Activities of Daily Living (ADL ' s) and pain/comfort will decrease within one hour after intervention through the next review date. These approaches includes but not limited to: Continued review of resident #125 care plan reveals he is coping with a terminal illness, and he has a goal to express his feelings and attitude relating to his [DIAGNOSES REDACTED]. -Refer to nursing for specific questions regarding care, pain control etc. Care plan review reveals resident #125 is under the care of Heartland Hospice due to terminal condition [MEDICAL CONDITION] of the pharynx. He has a goal that in house staff and Hospice will provide emotional support. Comfort measures will be provided by in house staff as well as Hospice staff. The approaches to reach these goals includes but are not limited to: -Monitor for pain and discomfort; provide comfort measures -If alert and able to communicate ask resident what his pain level is on a scale of 0-10; observe for non-verbal signs and symptoms of pain. -Medicate as prescribed with pain medication when pain is above 3 on a scale of 0-10 or when non-verbal signs and symptoms of pain. -Document effectiveness of pain medication. -Notify physician if pain medication is not effective. Record review of resident #125 physician orders dated 11/28/11 revealed consult Heartland Hospice for readmission. Record review of resident #125 Hospice folder revealed on 10/31/11 Election of Hospice benefit and consent to treat resident. Further review of resident #125 hospice folder Team Care Plan notes 11/1/11 revealed on 10/31/1 hospice will provide: Nurse 1 times a week for 13 weeks; 7 PRN: medical support Social Services 1 times a week for 3 months; 30 PRN: social services Spiritual support 1 times month for 3 months; 30 PRN: spiritual support Certified Nursing Assistance (CNA) 5 times a week for 13 weeks. Continued review of Hospice notes dated 11/8/11 revealed resident #125 was transferred from the south team to the north team. Interview on 12/16/11 at 10:34am with the Clinical Nurse Manger revealed resident #125 is on hospice for end [MEDICAL CONDITION] of pharynx and he is very independent. She also stated his pain is control by [MEDICATION NAME] and [MEDICATION NAME] for breakthrough pain. After reviewing MAR, and pain monitoring sheet the Clinical Nurse Manager confirmed on 11/4/11 and 12/5/11 resident did not get his [MEDICATION NAME] because it was unavailable by the pharmacy. She also confirmed after reviewing the hospice notes by the C-N-A on 11/14 and 11/21/11 resident did have swelling to his left foot and that the facility has been trying to contact hospice nurse to inform them and they did not respond; that the facility physician saw the resident on 12/12/11 and order ted hose. Surveyor then asked when the last time the hospice nurse had come to see the resident and where is the communication between the facility and hospice. Clinical Nurse Manager stated the nurse comes once a week to see resident; however, she was unable to tell the surveyor the last time the hospice nurse visited as she looked through resident #125 record and there was no documentation from the hospice nurse in the resident's hospice folder. She said resident #125 is on hospice but the facility is one taking care the resident because hospice do not respond and there is no hospice nurse documentation. Interview on 12/16/11 at 4:46pm with the Director of Nursing (DON) with the Clinical Care Manager present revealed she has spoken with the Hospice Team Manager and she has expressed her concerns about the physician not coming to see resident #125 and she was informed they do not send a physician. Surveyor requested to see some type of communication from hospice besides the C-N-A notes and she stated after looking through the folder she does not see any evidence of the hospice nurse visiting as well. She also confirmed she has called the case manager when there is something wrong with resident #125 and staff however, we have not been successful in reaching them as well. The only thing that has come up to my level is resident #125 had peg in and he wanted to eat and he was seen by speech and hospice approved it. Resident #125 was sent to the hospital for a [MEDICATION NAME] study. Resident went out one day for an appointment and came back without his peg. The DON stated that is what I am talking about, the facility was not aware hospice was taking out the resident tube. Surveyor then asked for the hospice policy and contract with hospice; and DON stated the facility was using a binder from another hospice as a guide. Interview on 12/16/11 at 5:14pm with the DON after looking at November and December 2011 pain monitoring sheet; the DON stated the nurse should be monitoring and assessing resident #125 for pain even if he does not get pain medication every day just to know the baseline. She also stated resident #125 should not run out of pain medication because he gets it every 72 hours and there are 5 patches in a box. The nurse should call the physician for a script when they use the last patch. The DON looked at November and December 2011 MAR and stated " I hate a messy MAR' " and confirmed resident #125 did not get [MEDICATION NAME] after reviewing the MAR for 11/4 and 12/5/11. Record review revealed resident #66 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in residents #66 ' s room on 12/14/11 at 9:45am revealed a home [MEDICAL TREATMENT] provider Certified [MEDICAL TREATMENT] Technician (CHT) preparing to administer [MEDICAL TREATMENT] services to services to resident #66 at her bedside. Observation on 12/14/11 at 9:45am revealed resident lying in bed. The resident appeared comfortably positioned in bed. No signs or symptoms of pain, but s/s pain or discomfort. Resident #66 offered no verbal response, but opened her eyes when spoken to. Observation revealed resident ' s eyes and surrounding area were slightly puffy and resident appeared congested when coughing. The CHT stated that the resident is congested and she states she will contact respiratory therapy for a breathing treatment. Observation on 12/14/11 at 10:00am revealed an enteral feeding system infusing Nepro (Renal formula) at 40ml(milliliters)/hour, with an auto flush infusing water at via PEG (percutaneous endoscopic gastrostomy) tube at 25ml/hour. . Observation at 10:20am revealed resident #66 ' s blood pressure at 173/92 and heart rate at 103. The CHT was observed checking the residents lung sounds using a stethoscope. She stated that the resident must be due for a breathing treatment for [REDACTED]. . Observation at 10:35am revealed [MEDICAL TREATMENT] treatment initiated with treatment scheduled for 3 hours and 15 minutes. Interview with the CHT on 12/14/11 at approximately 10:40am revealed resident #66 ' s previous post treatment weight on 12/12/11 was 160 lbs. Her pre-treatment weight on 12/14/11 was 161 lbs. The CHT states UF (ultra-filtration) volume is 2000 ml. When asked how this was determined she stated it was based on weight and blood pressure, stating that the resident blood pressure was elevated prior to starting treatment. The CHT stated the BFR (blood flow rate) is set at 350-400. She reported that the resident had to be sent to open access last week to have her catheter checked due to problems reaching the BFR. She reported the catheter is functioning properly now and she is able to reach 350 plus flow rate. When asked what the resident ' s target dry weight was she stated 80 kg (kilograms) which equals 176 lbs. When asked about the discrepancy between the target dry weight and the residents actual weight recorded at 161 lbs, the CHT had no explanation for the discrepancy stating only that the target weight was given to her by the [MEDICAL TREATMENT] center. Interview with the CHT on 12/14/11 at 11:00am revealed the resident ' s blood pressure (BP) was currently 163/82. The CHT reported that the respiratory therapist had already given the resident a breathing treatment this morning, but she did return to suction her during her [MEDICAL TREATMENT] treatment and she appeared less congested. Review of the Home [MEDICAL TREATMENT] Flow sheet completed by the CHT on 12/14/11 revealed the following information (not all inclusive): Pre and post Treatment Assessment. Pre- treatment: Last weight 80.0 kg/160.0 lbs Weight 80.5 kg / 161.0 lbs BP Sitting 173/92. HR (heart rate): 105. Temp 99.1 Dry weight: 80 kg. Interim gain: 0.5 kg. Lungs: Congested, [MEDICAL CONDITION] Eyes. Respiration: 20. Complaints: congestion and shortness of breath. Post Treatment: Weight loss 1.7 kg BP 138/72 HR 105 Respirations: 20 Temp 99.9 Lungs: clearer. Summary: Treatment finished. Patient is in stable condition. Patient pre-treatment was given a breathing treatment and she was suctioned by respiratory and her lung sounds are much better. Review of the data documented on the flow sheet reflects an error in converting weight in kilograms to pounds. Last weight of 160 lbs converts to 72.7 kg, not 80.0 kg as recorded on the flow sheet. The pre-treatment weight of 161 lbs converts to 73.1 kg, not 80.5 kg as documented on the flow sheet. Review of a telephone order dated 11/9/11 revealed an order for [REDACTED]. A telephone order dated 11/10/11: Dietary clarification reveals: Nepro at 40 cc/hour x 22 hours via PEG, change auto flush to 25 cc/hour x 22 hours via PEG, med flush of 30 cc water before and after meds, Pro-Stat 64 30 ml four times daily via PEG and [MEDICATION NAME] 15 ml daily via PEG. Review of the Nutrition Risk Assessment completed by the Dietetic Technician Registered (DTR) dated 11/10/11 reflects all of the above recommendations as noted on the telephone order dated 11/10/11; however, there is no documentation to reflect recognition of the 1000 cc fluid restriction ordered 11/9/11. Documentation reflects the following: Weight noted at 146 pounds. Calculated needs: Calories per Kg 25-30 kcal (kilocalories)/kg to equal total calorie needs 1650-1980. Protein needs are assessed at 1.5-2.0 grams/kg to equal 99-132 grams/day. Total fluids: to be determined by [MEDICAL TREATMENT]. Fluid restriction: (on PEG). Assessment notes admission post weight 146 lbs (66 kg). No significant weight change for 30/90 days. BMI (body mass index) is 30.5. Laboratory results assessed with [REDACTED]. Documented increased protein need/intake from enteral nutrition related increased needs for wound healing and [DIAGNOSES REDACTED]. Review of follow up Enteral Nutrition Assessment completed by the DTR on 12/5/11 documents current weight 12/5/11 160 pounds. Intake via tube feeding - Nepro @40 cc (cubic centimeters)/hour: 640 cc free water. Flush order: Auto flush at 25 cc/hour x 22 hours = 550 cc. Supplement order: Pro-Stat 64 30 ml four times daily = 288 kcal plus 60 gm protein (not included as fluid intake on assessment). Estimated fluid needs: to be determined by [MEDICAL TREATMENT]. Review of the documentation does not reflect the order for a 1000 ml fluid restriction and the calculated fluid intake does not include the additional fluid provided with the liquid medications (Pro-Stat 64 30 ml four times daily and [MEDICATION NAME] 15 ml daily) or the amount of water used daily to flush medications with 30 ml water before and after medications. The assessment summary notes current weight 160 pounds (post weight 12/5/11) 73 kg reflects a slight weight gain x 30 days (not planned). Review of the assessment does not reflect documentation that the weight gain signifies an actual significant/unplanned weight gain (+7.37% in < 30 days). Review of a nutritional progress note dated 12/11/11 written by the by the Consultant Registered Dietitian (RD) reflects review of DTR assessment completed 11/10/11. The RD documents agreement with interventions currently in place. The RD documented that review of weights reflect a 2-4 lb interdialytic weight gain. RD to monitor and follow-up as needed. The RD note does not reflect assessment of fluid needs, fluid intake or documentation of the fluid restriction ordered 11/9/11. The RD note does not reflect an assessment of the significant /unplanned weight gain of 7.37% in less than 30 days. There is no documentation that reflects the resident target dry weight following [MEDICAL TREATMENT] treatment. There is no documentation by the DTR or the RD to reflect communication with the [MEDICAL TREATMENT] center to determine fluid needs and the initial assessment reflects fluid needs to be determined by [MEDICAL TREATMENT]. Interview on 12/14/11 at approximately 11:00am with the DTR revealed that she was not aware this resident was currently on fluid restriction. Upon review of the nutritional assessment dated [DATE] with the DTR, she confirmed that resident #66 was currently receiving Nepro via PEG at 40 ml/ hour for 22 hours daily and the auto flush was 25 ml via PEG for 22 hours per day. The DTR stated that the fluid intake including the free water from the Nepro and the auto flush totaled 1190 cc per day. She stated that dietary was responsible for calculating the fluid intake if a resident was placed on a fluid restriction, but she was not aware there was an order for [REDACTED]. The DTR stated that she would call the dietitian at the [MEDICAL TREATMENT] center to confirm the order for the fluid restriction. Interview with the RD from the contracted [MEDICAL TREATMENT] center on 12/14/11 at approximately 12:30pm confirmed that resident #66's current treatment orders included a fluid restriction of 1000 cc daily, stating that a copy of the current orders would be faxed to the facility. The RD stated that it may be acceptable for the resident to receive slightly less than 1000 cc/day, between 900 and 1000 cc daily. The RD stated that the resident target dry weight was change between sometime between 11/14/11 and 11/16/11 from 65 kg (143 pounds) to 80 kg (176 pounds). The RD was informed that the last post treatment weight on file in the clinical record dated 12/12/11 was 161 pounds (73 kg). The RD stated that she would have to talk to the neurologist regarding adjusting the target dry weight. She was not sure why the target dry weight had been changed from 65 kg to 80 kg, but stated that she was not aware the resident ' s current weight was 161 lbs (73 kg). She did state that the target dry weights were determined by the weight information obtained from the nursing home. The RD reported that the dry weight would have to be adjusted in view of the current weight. The RD stated that she would confirm the current orders with the Nephrologist and fax a copy to the facility. The RD reported that she was not informed of the significant weight gain in the past 30 days. Review of the Home [MEDICAL TREATMENT] Program physician ' s orders faxed 12/15/11 at approximately 12 noon reflected orders to include, but not limited a fluid restriction of 1,000 ml/day. Record review reflects readmission weight 11/8/11 227.4 lbs, re-weight 148.2 lbs. Post treatment weights 11/11/1 149.6, 11/14/11 148.2, 11/16/11 145.2, 11/8/11 145.2, 11/21/11 144.8, 11/23/11 143.0, 11/25/11 146.2, 11/28/11 146.4, 11/30/11 147.2, 12/2/11 160.0, 12/5/11 159.2, 12/6/11 Monthly 160.0, 12/7/11 158.6, 12/9/11 158.6, 12/12/11 161.0, 12/14/11 161.0. Review of the weights reflects a weight gain of 7.37% in less than 30 days. Review of the December 2011 physicians order sheet reflects orders to include: Nepro @ 40 ml/hour via PEG tube x 22 hours. (880 ml = 640 free water) Water auto flush @ 25 ml/hour x 22 hours. (550 ml) [MEDICATION NAME] Liquid: give 15 ml via PEG tube daily Pro-Stat 64 liquid: give 30 ml via PEG tube four times per day (120 ml) Medication flush of 30 ml water before and after meds (review of medication administration record (MAR) reflects medications are ordered and administered 5 times daily to total 300 ml flush). Fluid Restriction: 1000 ml/day. Review of the above ordered enteral formula (free water), auto flush, medication pass flushes, Pro-Stat 64, and [MEDICATION NAME] provides a total of 1625 ml fluid daily. Review of the " Tube Feeding Record " on file in the clinical record reflects the following documented intake via PEG: Interview with the DTR on 12/16/11 at approximately 10:00am and review of current fluid intake based on orders confirms that resident #66 is receiving up to 1625 cc fluid daily based on enteral feeding, flush, liquid medications and medication pass flushes. She again stated that she was not aware of the fluid restriction order and that she does not calculated the med pass flushes in the total fluid intake for a resident on a tube feeding. The Nutrition Risk Assessments dated 11/10/11 and 12/5/11 reflect no evidence of communication with the [MEDICAL TREATMENT] program RD. Both assessments reflect fluid requirement to be determined by [MEDICAL TREATMENT]; however, there is no follow-up documentation that the fluid requirements had been determined. The DTR stated she consulted via telephone with the [MEDICAL TREATMENT] RD several times per week. Interview on 12/16/11 at approximately 8:45am with the Licensed Practical Nurse (LPN) on the third floor revealed resident #66 is frequently congested. Review of the medication administration record (MAR) with the LPN confirmed that the resident receives medication 5x day and the physician ' s order is to flush with 30 cc of water before and after each med pass to total 300 cc water daily. The LPN confirmed that the resident receives 30 ml of Pro-Stat 64 four times daily which totals 120 cc daily. She stated that a Tube Feeding Record of fluid intake record was maintained which only included the amount of Enteral feeding and auto flush administered through the PEG, stating that the pump was cleared and the end of each shift to obtain these totals. The LPN confirmed that these totals did not include the additional flushes provided with medication pass or the liquid medications provided. Review of the " Tube Feeding Record " on file in the clinical records reflects amount of input separated into two columns, one for milk and the other for flush. Review of the intake documented on the tube feeding record reflects intake greater than 1000 cc fluid daily from 11/9/11 through 12/15/11. The average intake of milk per day was 897 cc (652 cc free water) and the average flush was 549 cc water to total 1201 cc per day. Interview with the Consultant RD on 12/16/11 at approximately 11:45am revealed that she was not aware resident #66 was supposed to be on a fluid restriction. She then stated that if a resident has an order for [REDACTED]. She stated that if a resident receives a tube feeding and is on the fluid restriction, dietary is still responsible for calculating all fluids provided to include the feeding, flush and additional liquid medications and fluids given with medications. The RD stated that she was not aware of the significant weight gain in the past 30 days and confirmed that there was no assessment related to the weight results. Interview with the Director of Nursing (DON) on 12/16/11 at approximately 12:05pm and review of the weight meeting minutes revealed that there is no documentation that the significant weight gain for R#66 was discussed at the weight meeting. The DON stated weights for residents on [MEDICAL TREATMENT] are maintained in the [MEDICAL TREATMENT] book since they have pre and post treatment weights done three times per week. She states she relies on the DTR to provide the information related to significant weight changes. The DON stated that all residents with a significant weight changes are re-weighed to confirm accuracy. Review of the weight record for R#66 with the DON and the RD confirmed that R#66 had a significant weight gain and had not been re-weighed. The DON stated that the physician is notified of all significant weight changes including gains and losses. She stated that the DTR should have a note in the dietary progress notes to address the weight change and once the physician is notified by the nurse, a nurse ' s note is written regarding the notification to the physician. Review of the dietary assessment written by the DTR and the RD with the RD present confirmed no documentation of the significant weight gain. Review of the nursing progress notes and the physician ' s progress notes with the Clinical Nurse Manager confirmed that there was no documented evidence that the physician was notified of the significant weight change. Interview with the [MEDICAL TREATMENT] provider RD on 12/16/11 via telephone at 2:55pm revealed this patient ' s dry weight was misdocumented . Our DON needs to review the calculations on how to convert pounds to kilograms with the technicians. I just recently began to document and review my December weights. I had just began to review our flow sheets and noted that the dry weight of 80kg is not correct and that the resident had a significant weight gain. She stated that she has frequent communication with the facility DTR. I was not alerted that there was a significant weight gain. We will have to follow-up to teach our staff how to accurately calculate the dry weight and covert weights from pounds to kilograms. I will also need to follow-up to discuss the recent significant weight gain since I was not notified of the change. The RD again confirmed that the resident has orders for a 1000 cc fluid restriction daily. I will inform our DON that the flow sheets are not accurate. This patient ' s dry weight is definitely not 80 kg as documented. Review of the facility policy and procedure titled: Fluid Restriction (includes, but is not limited to): The facility is responsible for insuring that all residents receive adequate intake within the limitations determined by the physician. A written order will be obtained from the attending physician. Keep in mind fluid required for resident to take medications. The care plan team will discuss the restrictions, and they will be included in the care plan. The dietitian will document the allowed fluids in the medical record and provide a written breakdown to the nursing staff. In the event that a resident receives nutrition and hydration via tube feeding, the Dietitian/Diet Technician will calculate fluid intake to ensure compliance to the fluid restriction ordered, taking into consideration the amount of feeding, water flushes and liquid medication. Review of the facility policy and procedure titled: Weight Assessment and Intervention: (includes, but not limited to) 3. Any weight change of greater than or less than 5 pounds in thirty days will be retaken the next day for confirmation. If verified, nursing will immediately notify the dietitian in writing. The dietitian will respond with 24 hours. Significant weight changes are defined as: more or less than 5% in 30 days. If the weight change is desirable, this will be documented and no change in the care plan is necessary. .

Based on observation, interview and record review the facility failed to properly assess a residents nutritional status and provide a therapeutic nutritional regimen to assure maintenance of acceptable nutritional parameters for 1 (resident #66) of 1 resident of 29 stage 2 sampled residents reviewed for nutrition and [MEDICAL TREATMENT] . This was evidenced by failure to maintain a fluid restriction as ordered, failure to appropriately assess and calculate fluid intake, failure to assess the resident following a significant/unplanned weight gain, and failure to identify nutritional risk factors and maintain nutritional interventions based on residents needs and goals related to a [DIAGNOSES REDACTED]. The findings include: Record review revealed resident #66 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in residents #66 ' s room on 12/14/11 at 9:45am revealed a home [MEDICAL TREATMENT] provider Certified [MEDICAL TREATMENT] Technician (CHT) preparing to administer [MEDICAL TREATMENT] services to services to resident #66 at her bedside. Observation on 12/14/11 at 10:00am revealed an enteral feeding system infusing Nepro (Renal formula) at 40ml(milliliters)/hour, with an auto flush infusing water at via PEG (percutaneous endoscopic gastrostomy) tube at 25ml/hour. Review of the Home [MEDICAL TREATMENT] Flow sheet completed by the CHT on 12/14/11 revealed the following information (not all inclusive): Pre and post Treatment Assessment. Pre- treatment: Last weight 80.0 kg/160.0 lbs Weight 80.5 kg / 161 lbs Dry weight: 80 kg. Interim gain: 0.5 kg. Review of the data documented on the flow sheet reflects an error in converting weight in kilograms to pounds. Last weight of 160 lbs converts to 72.7 kg, not 80.0 kg as recorded on the flow sheet. The pre-treatment weight of 161 lbs converts to 73.1 kg, not 80.5 kg as documented on the flow sheet. Review of a telephone order dated 11/9/11 revealed an order for [REDACTED]. Review of the Nutrition Risk Assessment completed by the Dietetic Technician Registered (DTR) dated 11/10/11 reflects all of the above recommendations as noted on the telephone order dated 11/10/11; however, there is no documentation to reflect recognition of the 1000 cc fluid restriction ordered 11/9/11. Documentation reflects the following: Weight noted at 146 pounds. Calculated needs: Calories per Kg 25-30 kcal (kilocalories)/kg to equal total calorie needs 1650-1980. Protein needs are assessed at 1.5-2.0 grams/kg to equal 99-132 grams/day. Total fluids: to be determined by [MEDICAL TREATMENT]. Fluid restriction: (on PEG). Assessment notes admission post weight 146 lbs (66 kg). No significant weight change for 30/90 days. BMI (body mass index) is 30.5. Laboratory results assessed with [REDACTED]. Documented increased protein need/intake from enteral nutrition related increased needs for wound healing and [DIAGNOSES REDACTED]. Review of follow up Enteral Nutrition Assessment completed by the DTR on 12/5/11 documents current weight 12/5/11 160 pounds. Intake via tube feeding - Nepro @40 cc (cubic centimeters)/hour: 640 cc free water. Flush order: Auto flush at 25 cc/hour x 22 hours = 550 cc. Supplement order: Pro-Stat 64 30 ml four times daily = 288 kcal plus 60gm protein (not included as fluid intake on assessment). Estimated fluid needs: to be determined by [MEDICAL TREATMENT]. Review of the documentation does not reflect the order for a 1000 ml fluid restriction and the calculated fluid intake does not include the additional fluid provided with the liquid medications (Pro-Stat 64 30 ml four times daily and [MEDICATION NAME] 15 ml daily) or the amount of water used daily to flush medications with 30 ml water before and after medications. The assessment summary notes current weight 160 pounds (post weight 12/5/11) 73 kg reflects a slight weight gain x 30 days (not planned). Review of the assessment does not reflect documentation that the weight gain signifies an actual significant/unplanned weight gain (+7.37% in < 30 days). Review of a nutritional progress note dated 12/11/11 written by the by the Consultant Registered Dietitian (RD) reflects review of DTR assessment completed 11/10/11. The RD documents agreement with interventions currently in place. The RD documented that review of weights reflect a 2-4 lb interdialytic weight gain. RD to monitor and follow-up as needed. The RD note does not reflect assessment of fluid needs, fluid intake or documentation of the fluid restriction ordered 11/9/11. The RD note does not reflect an assessment of the significant /unplanned weight gain of 7.37% in less than 30 days. There is no documentation that reflects the resident target dry weight following [MEDICAL TREATMENT] treatment. There is no documentation by the DTR or the RD to reflect communication with the [MEDICAL TREATMENT] center to determine fluid needs and the initial assessment reflects fluid needs to be determined by [MEDICAL TREATMENT]. Interview on 12/14/11 at approximately 11:00am with the DTR revealed that she was not aware this resident was currently on fluid restriction. Upon review of the nutritional assessment dated [DATE] with the DTR, she confirmed that resident #66 was currently receiving Nepro via PEG at 40 ml/ hour for 22 hours daily and the auto flush was 25 ml via PEG for 22 hours per day. The DTR stated that the fluid intake including the free water from the Nepro and the auto flush totaled 1190 cc per day. She stated that dietary was responsible for calculating the fluid intake if a resident was placed on a fluid restriction, but she was not aware there was an order for [REDACTED]. Interview with the RD from the contracted [MEDICAL TREATMENT] center on 12/14/11 at approximately 12:30pm confirmed that resident #66's current treatment orders included a fluid restriction of 1000 cc daily, stating that a copy of the current orders would be faxed to the facility. The RD stated that it may be acceptable for the resident to receive slightly less than 1000 cc/day, between 900 and 1000 cc daily. The RD stated that the resident target dry weight was change between sometime between 11/14/11 and 11/16/11 from 65 kg (143 pounds) to 80 kg (176 pounds). The RD was informed that the last post treatment weight on file in the clinical record dated 12/12/11 was 161 pounds (73 kg). The RD stated that she would have to talk to the neurologist regarding adjusting the target dry weight. She was not sure why the target dry weight had been changed from 65 kg to 80 kg, but stated that she was not aware the resident ' s current weight was 161 lbs (73 kg). She did state that the target dry weights were determined by the weight information obtained from the nursing home. The RD reported that the dry weight would have to be adjusted in view of the current weight. The RD stated that she would confirm the current orders with the Nephrologist and fax a copy to the facility. The RD reported that she was not informed of the significant weight gain in the past 30 days. Review of the Home [MEDICAL TREATMENT] Program physician ' s orders faxed 12/15/11 at approximately 12 noon reflected orders to include, but not limited a fluid restriction of 1,000 ml/day. Record review reflects readmission weight 11/8/11 227.4 lbs, re-weight 148.2 lbs. Post treatment weights 11/11/1 149.6, 11/14/11 148.2, 11/16/11 145.2, 11/8/11 145.2, 11/21/11 144.8, 11/23/11 143.0, 11/25/11 146.2, 11/28/11 146.4, 11/30/11 147.2, 12/2/11 160.0, 12/5/11 159.2, 12/6/11 Monthly 160.0, 12/7/11 158.6, 12/9/11 158.6, 12/12/11 161.0, 12/14/11 161.0. Review of the weights reflects a weight gain of 7.37% in less than 30 days. Review of the December 2011 physicians order sheet reflects orders to include: Nepro @ 40 ml/hour via PEG tube x 22 hours. (880 ml = 640 free water) Water auto flush @ 25 ml/hour x 22 hours. (550 ml) [MEDICATION NAME] Liquid: give 15 ml via PEG tube daily Pro-Stat 64 liquid: give 30 ml via PEG tube four times per day (120 ml) Medication flush of 30 ml water before and after meds (review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Fluid Restriction: 1000 ml/day. Review of the above ordered enteral formula (free water), auto flush, medication pass flushes, Pro-Stat 64, and [MEDICATION NAME] provides a total of 1625 ml fluid daily. Review of the " Tube Feeding Record " on file in the clinical record reflects the following documented intake via PEG: Interview with the DTR on 12/16/11 at approximately 10:00am and review of current fluid intake based on orders confirms that resident #66 is receiving up to 1625 cc fluid daily based on enteral feeding, flush, liquid medications and medication pass flushes. She again stated that she was not aware of the fluid restriction order and that she does not calculated the med pass flushes in the total fluid intake for a resident on a tube feeding. The Nutrition Risk Assessments dated 11/10/11 and 12/5/11 reflect no evidence of communication with the [MEDICAL TREATMENT] program RD. Both assessments reflect fluid requirement to be determined by [MEDICAL TREATMENT]; however, there is no follow-up documentation that the fluid requirements had been determined. The DTR stated she consulted via telephone with the [MEDICAL TREATMENT] RD several times per week. Interview on 12/16/11 at approximately 8:45am with the Licensed Practical Nurse (LPN) on the third floor nurse revealed resident #66 is frequently congested. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The LPN confirmed that the resident receives 30 ml of Pro-Stat 64 four times daily which totals 120 cc daily. She stated that a Tube Feeding Record of fluid intake record was maintained which only included the amount of Enteral feeding and auto flush administered through the PEG, stating that the pump was cleared and the end of each shift to obtain these totals. The LPN confirmed that these totals did not include the additional flushes provided with medication pass or the liquid medications provided. Review of the "Tube Feeding Record " on file in the clinical records reflects amount of input separated into two columns, one for milk and the other for flush. Review of the intake documented on the tube feeding record reflects intake greater than 1000 cc fluid daily from 11/9/11 through 12/15/11. The average intake of milk per day was 897 cc (652 cc free water) and the average flush was 549 cc water to total 1201 cc per day. Interview with the Consultant RD on 12/16/11 at approximately 11:45am revealed that she was not aware resident #66 was supposed to be on a fluid restriction. She then stated that if a resident has an order for [REDACTED]. The RD stated that she was not aware of the significant weight gain in the past 30 days and confirmed that there was no assessment related to the weight results. Interview with the Director of Nursing (DON) on 12/16/11 at approximately 12:05pm and review of the weight meeting minutes revealed that there is no documentation that the significant weight gain for R#66 was discussed at the weight meeting. The DON stated weights for residents on [MEDICAL TREATMENT] are maintained in the [MEDICAL TREATMENT] book since they have pre and post treatment weights done three times per week. She states she relies on the DTR to provide the information related to significant weight changes. The DON stated that all residents with a significant weight changes are re-weighed to confirm accuracy. Review of the weight record for R#66 with the DON and the RD confirmed that R#66 had a significant weight gain and had not been re-weighed. The DON stated that the physician is notified of all significant weight changes including gains and losses. She stated that the DTR should have a note in the dietary progress notes to address the weight change and once the physician is notified by the nurse, a nurse ' s note is written regarding the notification to the physician. Review of the dietary assessment written by the DTR and the RD with the RD present confirmed no documentation of the significant weight gain. Review of the nursing progress notes and the physician ' s progress notes with the Clinical Nurse Manager confirmed that there was no documented evidence that the physician was notified of the significant weight change. Interview with the [MEDICAL TREATMENT] provider RD on 12/16/11 via telephone at 2:55pm revealed this patient ' s dry weight was " misdocumented " . Our DON needs to review the calculations on how to convert pounds to kilograms with the technicians. I just recently began to document and review my December weights. I had just began to review our flow sheets and noted that the dry weight of 80kg is not correct and that the resident had a significant weight gain. She stated that she has frequent communication with the facility DTR. I was not alerted that there was a significant weight gain. We will have to follow-up to teach our staff how to accurately calculate the dry weight and covert weights from pounds to kilograms. I will also need to follow-up to discuss the recent significant weight gain since I was not notified of the change. The RD again confirmed that the resident has orders for a 1000 cc fluid restriction daily. I will inform our DON that the flow sheets are not accurate. This patient ' s dry weight is definitely not 80 kg as documented. Review of the facility policy and procedure titled: Fluid Restriction (includes, but is not limited to): The facility is responsible for insuring that all residents receive adequate intake within the limitations determined by the physician. A written order will be obtained from the attending physician. Keep in mind fluid required for resident to take medications. The care plan team will discuss the restrictions, and they will be included in the care plan. The dietitian will document the allowed fluids in the medical record and provide a written breakdown to the nursing staff. In the event that a resident receives nutrition and hydration via tube feeding, the Dietitian/Diet Technician will calculate fluid intake to ensure compliance to the fluid restriction ordered, taking into consideration the amount of feeding, water flushes and liquid medication. Review of the facility policy and procedure titled: Weight Assessment and Intervention: (includes, but not limited to) 3. Any weight change of greater than or less than 5 pounds in thirty days will be retaken the next day for confirmation. If verified, nursing will immediately notify the dietitian in writing. The dietitian will respond with 24 hours. Significant weight changes are defined as: more or less than 5% in 30 days. If the weight change is desirable, this will be documented and no change in the care plan is necessary. .