Every finding on record at Givens Health Center

Based on record review and staff interviews, the facility failed to accurately code the fall history on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accidents (Resident #4).Findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, heart failure, and dementia. Review of the nurse's progress note dated 08/22/2025, a fall event record dated 09/06/2025, and the nurse's progress note dated 09/26/2025 revealed Resident #4 had three unwitnessed falls in her room where she was found sitting on floor. The notes and fall record revealed after each fall the nurse assessed Resident #4 and Resident #4 had no injury. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had no falls since the prior assessment. During an interview of 03/18/2026 at 2:29 PM, the MDS Coordinator confirmed she completed Resident #4's fall history on the annual MDS dated [DATE]. She explained she reviewed the resident's fall event history when completing the assessment and coded any falls that occurred after the prior MDS. The MDS Coordinator confirmed the prior MDS was completed on 07/16/2025 and any falls from 07/17/2025 through 10/15/2025 should have been coded on Resident #4's annual MDS. She reviewed the nurse's progress notes and fall event history and stated the annual MDS dated [DATE] should have been coded to reflect 2 or more falls without injury and she would modify Resident #4's assessment. During an interview on 03/18/2026 at 2:59 PM, the Director of Nursing (DON) stated MDS assessments should be accurate and correctly coded. The DON indicated she expected the annual MDS dated [DATE] reflected Resident #4 had two or more falls without injury.During an interview on 03/18/2026 at 3:02 PM, the Administrator stated MDS assessments should be accurate and correctly coded, and the annual MDS dated [DATE] should have been coded to reflect Resident #4 had fallen since the prior assessment.

Based on observations and staff interviews, the facility failed to ensure 5 of 36 dishes ready for use on the tray line were free from dried scattered crumb like particles, provide expiration dates for 4 of 4 frozen boxes of pureed foods, label and date one stainless steel container of gravy and four cookie sheets of bacon that was located in 1 of 5 reach in coolers, and ensure 1 of 4 dietary staff restrained hair during food preparation. These practices had the potential to affect food served to residents. Findings included: 1. During the initial tour of the kitchen on 02/03/2025 at 11:12 AM the following areas of concern were observed. Two white scoop bowls with a yellow/orange substance on the bottom and side of each bowl and three divided plates with yellow/orange dried scattered crumb like particles. The dishes were observed on the tray line, ready to be used. On 2/5/25 at 11:05 AM Dietary Assistant #2 was interviewed. She explained she was one of three people who checked the dishes for cleanliness. Dietary Assistant #2 revealed the person who pulled the dishes out of the dishwasher should be checking for cleanliness, the dishes should be checked again when moved to storage and a third time when moved to the tray line. She stated if dirty dishes were found on the tray line, then one of the three steps were not completed. The interview on 2/3/25 at 11:15 AM with Dietary Manager #1 indicated the procedure for assuring dishes are clean before using was a three-step process. The first check occurred when dishes were removed from the dishwasher, the second check occurred when the dishes were put into storage and then a third time when dishes were moved to the tray line for use. The interview with the Administrator on 2/6/25 at 2:19 PM indicated he expected the facility to follow the policies and procedures of providing clean dishes to the residents. 2. During a continued initial tour of the kitchen on 02/03/2025 at 11:20 AM, the following items were noted in a reach in cooler: one stainless steel container with gravy with no date; four sheet pans of bacon covered with parchment paper with no date; one open box containing twenty-three packages of frozen pureed green beans with no use by dates marked; one open box containing twenty-four packages of frozen pureed seasoned peas with no used by dates marked; one closed box and one open box for a total of thirty-nine packages of pureed corn on the cob with no use by date marked. Interview with Dietary Assistant #1 on 2/6/25 at 10:20 AM indicated he thought pureed frozen foods were good for six months after the printed packaged on date. He reported that if food had been in the cooler for six months, he threw it away. An interview with Dietary Manager #1 on 02/02/2025 at 11:25 AM indicated the bacon and gravy were part of the daily prep for breakfast and everyone, just knows that it was prepared the day before. Dietary Manager #1 revealed he did not know how long after the printed packaged on date the frozen pureed food was good. He was observed to ask the person who ordered the food and Dietary Manager #1 reported he wasn't sure but thought it was one year. Documentation provided by Dietary Manager #1 revealed pureed frozen foods were considered usable for 32 months after the packaged-on date printed on the containers. During an interview with the Administrator on 2/6/25 at 2:19 PM he indicated he expected the facility to follow the policies and procedures of dating food containers. 3. On 2/5/25 at 11:10 AM during the process of checking food temperatures on the steam table, Dietary Aide #1 was observed leaning over the food to assess temperatures. Dietary Aide #1 was observed with facial hair approximately an inch long. He was not wearing a hair restraint on his face. An interview with the Dietary Manager #1 on 2/5/25 11:12 AM indicated that all employees were expected to wear appropriate hair covering when preparing food. During an interview with Dietary Aide #1 on 2/6/25 at 10:20 AM, he indicated kitchen staff were always supposed to have a hair restraint on head and face if they have a beard when working around food. He reported he thought his hair was about three inches long and was observed to sit just above the top of his shoulders. He reported his beard was about a quarter to one inch long and was observed to not hang off his chin. An interview with the Administrator on 2/6/25 at 2:19 PM indicated he expected staff to follow the policies and procedures for wearing hair restraints.

Based on record review, observation, staff and physician interviews, the facility failed to ensure residents had pain patches removed at bedtime as ordered for 2 of 29 residents reviewed for medication errors (Residents #45 and #31). Findings included: 1. Resident #45 was admitted on [DATE] with multiple diagnoses including wedge compression fracture of the thoracic vertebrae numbers 11-12 (lower end of the middle section of the spine) and low back pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was severely cognitively impaired and was documented as requiring pain management. The physician order dated 1/23/25 read apply one Lidoderm (local anesthetic pain patch that contains lidocaine) 5% topical patch to T12 spine area every morning, remove Lidoderm patch each night at bedtime. A Medication Administration observation of Medication Aide (MA) #1 on 02/05/25 at 8:15 AM revealed a lidocaine patch was left in place on Resident #45's lower back dated 2/4/25. During an interview on 02/05/25 at 9:00 AM with MA #1, the MA verbalized that the overnight nurse must have forgotten to remove the pain patch from Resident #45's lower back at bedtime. In a phone interview on 02/06/25 at 7:30 AM, Nurse #1 confirmed she was the nurse for Resident #45 from 6:00pm on 2/4/25 to 6:00am on 2/5/25. Nurse #1 verbalized that, per physician order, pain patches are to be removed at bedtime. Nurse #1 stated that she got busy and forgot to remove the Lidocaine patch from Resident #45. During an interview on 02/06/25 at 11:04 AM with the facility's Physician, the Physician stated she expected staff to follow physician orders to remove a pain patch at bedtime. The Physician verbalized there was a low risk of skin irritation if the pain patch was left in place overnight. In an interview on 02/06/25 at 1:45 PM, the Director of Nursing (DON) stated that she expected nursing staff to follow physician orders. The DON also verbalized that the nurse should have removed the patch at bedtime from Resident #45 as ordered. During an interview on 02/06/25 at 2:00 PM with the Administrator, the Administrator stated that he would defer to the clinical team, but the expectation was for staff to document properly and to follow physician orders. 2. Resident #31 was admitted on [DATE] with multiple diagnoses including pain in the right shoulder. The physician order dated 4/4/24 read to apply lidocaine (local anesthetic pain patch that contains lidocaine) 5% topical patch to the right shoulder every morning and remove the patch each night at bedtime. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had normal cognitive function and was documented as requiring pain management. A Medication Administration observation of Medication Aide (MA) #1 on 02/05/25 at 08:45 AM revealed a lidocaine patch was left in place on Resident #31's right shoulder dated 2/4/25. During an interview on 02/05/25 at 09:00 AM with MA #1, MA #1 verbalized that the overnight nurse must have forgotten to remove the pain patch from Resident #31's right shoulder at bedtime. In a phone interview on 02/06/25 at 07:30 AM With Nurse #1, Nurse #1 confirmed she was the nurse for Resident #31 from 6:00pm on 2/4/25 to 6:00am on 2/5/25. Nurse #1 verbalized that, per physician order, pain patches are to be removed at bedtime. Nurse #1 stated she got busy and forgot to remove the Lidocaine patch from Resident #31 at bedtime. During an interview on 02/06/25 at 11:04 with the facility's Physician, the Physician stated she expected staff to follow physician orders to remove a pain patch at bedtime. The Physician verbalized there was a low risk of skin irritation if the pain patch was left in place overnight. In an interview on 02/06/25 at 1:45 PM with the Director of Nursing (DON), the DON stated she expected nursing staff to follow physician orders. The DON also verbalized that the nurse should have removed the patch at bedtime for Resident #31. During an interview on 02/06/25 at 2:00 PM with the Administrator, the Administrator stated that he would defer to the clinical team, but the expectation was for staff to document properly and to follow physician orders.

Based on observation, record review, and staff and physician interviews the facility failed to ensure a resident was provided supplemental oxygen per physician's orders for 1 of 2 residents (Resident #43) reviewed for oxygen. findings included: Resident #43 was admitted to the facility on [DATE] with multiple diagnoses that included acute respiratory failure with hypoxia (an absence of enough oxygen to sustain bodily functions). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was severely cognitively impaired and was documented as requiring supplemental oxygen. The physician's order dated 10/29/24 read to administer oxygen at 2 to 3 liters per minute via nasal canula. An observation of Resident #43 occurred on 02/04/25 at 9:00 AM. Resident #43 was observed in the sitting area on the 300 hall watching television. The resident's nasal canula was in place in the resident's nostrils and the tubing was connected to a portable oxygen tank secured to the back of Resident #43's wheelchair. While observing the gauge on the portable oxygen tank, the level of oxygen was in the red zone which showed the tank was almost empty. Another observation occurred on 02/04/25 at 9:30 AM. Resident #43 was observed in the sitting area of hall 300 and his portable oxygen tank gauge remained in the red zone. On 02/04/25 at 11:13 AM Resident #43 was observed sitting in the dining room adjacent to the front lobby of the facility. Resident #43's portable oxygen tank gauge was observed to be on empty. The resident was not observed to be in any respiratory distress at this time. Further observation of Resident #43 occurred on 02/04/25 at 11:27 AM. The resident was observed in the dining room. The portable oxygen tank gauge continued to read empty. Resident #43 was not in any respiratory distress at this time. On 02/04/25 11:33 AM Medication Aide (MA) #1 was interviewed. The MA explained when a resident was on a portable oxygen tank, she would check the tank periodically to ensure the tank would not become empty. She further explained that any staff member could assist a resident with their portable oxygen tanks. MA #1 stated Nursing Assistant (NA) #1 had applied the portable oxygen tank to Resident #43 prior to taking him to the sitting area this morning. She also stated she had not checked Resident #43's portable oxygen tank today (02/04/25). NA #1 was interviewed on 02/04/25 at 11:40 AM. The NA stated she normally checked residents' portable oxygen tanks every 30 minutes if the tank was already low. NA #1 explained if a resident was off the hall for reasons, such as activities, staff usually would come to let her know that the tank was low. The NA stated she had not checked Resident #43's portable oxygen tank since he left the hall for activities and lunch. On 02/06/25 at 11:04 AM the Physician was interviewed. The Physician stated that she expected portable oxygen tanks to be checked hourly while in use. She also stated she was not sure what the facility protocol was regarding who should check portable oxygen tanks. The Director of Nursing (DON) was interviewed on 02/06/25 at 1:45 PM. The DON stated activities staff, NAs and other dining room staff were expected to check portable oxygen tanks and report to nursing staff if tanks were low. She further stated that not everyone had been trained to monitor portable oxygen tanks. During an interview with the Administrator on 02/06/25 at 2:00 PM the Administrator stated he would defer the issue to the clinical team, but he expected all staff members to monitor and ensure resident's safety.

Based on record review, observation, staff and physician interviews, the facility failed to ensure accurate documentation in the medical record for 2 of 29 residents (Residents #45 and #31) reviewed for accurate medical records. Findings included: 1. Resident #45 was admitted on [DATE]. The physician's order dated 1/23/25 read apply one Lidoderm (local anesthetic pain patch that contains lidocaine) 5% topical patch to T12 spine area every morning, remove Lidoderm patch each night at bedtime. A review of Resident #45's Medication Administration Record (MAR) for the month of February 2025 revealed Nurse #1 had documented the removal of the Lidocaine pain patch from Resident #45's lower back at 8:00 PM on 02/04/25. A medication pass observation of Medication Aide (MA) #1 on 02/05/25 at 8:15 AM revealed a lidocaine patch was left in place on Resident #45's lower back dated 2/4/25. During an interview on 02/05/25 at 09:00 AM with MA #1, the MA verbalized that the overnight nurse must have forgotten to remove the pain patch from Resident #45's lower back at bedtime. In a phone interview on 02/06/25 at 07:30 AM, Nurse #1 confirmed she was the nurse for Resident #45 from 6:00 PM on 2/4/25 to 6:00 AM on 2/5/25. Nurse #1 stated that she had documented the task as completed in the electronic medical record of Resident #45 but then got busy and forgot to remove the Lidocaine patch from Resident #45. In an interview on 02/06/25 at 1:45 PM, the Director of Nursing (DON) stated that the nurse should not have documented that the pain patch was removed until after the task was completed. During an interview on 02/06/25 at 2:00 PM with the Administrator, the Administrator stated that he would defer to the clinical team, but the expectation was for staff to document accurately. 2. Resident #31 was admitted on [DATE]. The physician order dated 4/4/24 read to apply lidocaine (local anesthetic pain patch that contains lidocaine) 5% topical patch to the right shoulder every morning and remove the patch each night at bedtime. A review of Resident #31's Medication Administration Record (MAR) for February 2025 revealed Nurse #1 had documented the removal of the pain patch from Resident #31's right shoulder at 08:00 PM on 02/04/25. A medication pass observation of Medication Aide (MA) #1 on 02/05/25 at 08:45 AM revealed a lidocaine patch was left in place on Resident #31's right shoulder dated 2/4/25. During an interview on 02/05/25 at 09:00 AM with MA #1, MA #1 verbalized that the overnight nurse must have forgotten to remove the pain patch from Resident #31's right shoulder at bedtime. In a phone interview on 02/06/25 at 07:30 AM With Nurse #1, Nurse #1 confirmed she was the nurse for Resident #31 from 6:00pm on 2/4/25 to 6:00am on 2/5/25. Nurse #1 stated she had documented the task as completed in the electronic medical record of Resident #31 but then got busy and forgot to remove the Lidocaine patch from Resident #31 at bedtime. In an interview on 02/06/25 at 1:45 PM with the Director of Nursing (DON), the DON stated that the nurse should not have documented that the pain patch was removed until after the task was completed During an interview on 02/06/25 at 2:00 PM with the Administrator, the Administrator stated that he would defer to the clinical team, but the expectation was for staff to document accurately.

Based on record review, observation, and staff and physician interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a urinary catheter for when Nursing Assistant (NA) #1 emptied the resident's urinary catheter bag without wearing a gown for 1 of 2 staff (NA #1) observed for infection control practices. Findings included: The facility's policy titled Enhanced Barrier Precautions revised on 6/2024 states EBP refers to an infection control intervention designed to reduce transmission of multi-drug organisms that employs targeted gown, and gloves use during high contact resident care activities. Observation of Resident #43's door on 02/02/25 at 12:15 PM revealed signage for Enhanced Barrier Precautions. The signage indicated that staff who are performing direct care to Resident #43 required a gown and gloves to be worn. Further observation revealed a caddy outside of Resident #43's door that contained Personal Protective Equipment (PPE) such as gowns and gloves. An observation was made of Resident #43 on 02/03/25 at 12:34 PM. Resident #43's call light had been activated. Nursing Assistant (NA) #1 was observed entering Resident #43's room and Resident #43 explaining he needed his catheter bag emptied. NA #1 was observed emptying resident's urine catheter leg bag without wearing a gown. An interview was conducted with NA #1 on 02/03/25 at 12:45 PM. The NA was asked for examples of why a resident would be on EBP. NA #1 stated EBP was usually implemented for residents with a catheter and for other reasons but could not recall any other reasons. The NA remembered having one meeting about EBP. NA #1 could not recall having any other education regarding EBP. The NA stated she was aware Resident #43 was on EBP and that she should have been wearing a gown and gloves to empty the resident's catheter. NA #1 stated she just forgot. The physician was interviewed on 2/06/25 at 11:04 AM. The physician stated she expected staff to follow EBP protocol when giving direct care to residents with a catheter. The physician stated there was a lower risk to the residents if a gown was worn for emptying a catheter. An interview was conducted with the Director of Nursing (DON) on 02/06/25 at 1:45 PM. The DON confirmed that staff should be wearing a gown and gloves when giving direct care to residents such as changing the resident in bed, emptying a catheter, or helping a resident to the bathroom. The DON could not state why NA #1 had not worn a gown while providing direct care to Resident #43. The Administrator was interviewed on 02/06/25 at 2:00 PM. The Administrator stated that staff were educated regarding EBP annually and during the annual skills fair. The Administrator stated staff were expected to wear all PPE as needed.

Based on observation, record review, family and staff interviews the facility failed to honor a resident's choice to have a beard for 1 of 2 residents (Resident #10) reviewed for choices. The finding included: Resident #10 was admitted to the facility 11/02/22. A significant change Minimum Data Set assessment dated [DATE] indicated that Resident #10 had severe cognitive impairment. On 12/18/23 at 3:39 PM an interview was conducted with Resident #10's family member and an observation were made of Resident #10 during the interview. Resident #10 was sitting in a semi reclined position sleeping. He was neatly groomed with a light growth of a gray beard and mustache. The family member explained that the Resident was always very particular about his facial hair and kept his beard and mustache neatly groomed for the past [AGE] years or more. She indicated if Resident #10 understood that his beard had been shaved off, he would have been disappointed. She continued to explain that a while back she came in to find that someone had shaved half of her husband's beard off. The family member stated she posted several signs in his room directing the staff not to shave his beard but then she came to the facility on e day last week to find that this time someone had shaved his whole beard off. Resident #10's family member expressed the Resident had maintained his beard for 30 plus years. The Resident's family member stated she addressed her concern with Nurse Supervisor #1. At 4:00 PM on 12/18/23 an observation was made of Resident #10's room accompanied by the Resident's family member. There were 3 different signs posted around the Resident's room and bathroom of various directions: do not shave Resident #10's sideburns, stop shaving his cheeks and stop shaving Resident #10's cheeks, he is supposed to have a full beard, not a goatee. An interview was conducted with Nurse Supervisor #1 on 12/20/22 at 11:50 AM. The Supervisor acknowledged that Resident #10's family member came in to find that the Resident's beard had been completely shaved off and was upset at what she found. The Supervisor stated she assured the family member that she would investigate the incident and reported it to the Director of Nursing. Interviews were conducted with the Director of Nursing (DON) on 12/20/23 at 12:53 PM and 12/21/23 at 10:10 AM. The DON explained that she was informed of Resident #10's beard being shaved off. The DON stated she apologized to the family member and informed her that Nurse Aide (NA) #1 who was a fairly new nurse aide at the facility had shaved the Resident and despite multiple signs posted around his room she did not notice the signs until after she had finished his shave. The DON stated the NA made a mistake and shaved Resident #10 thinking he needed to be shaved. During an interview with Nurse Aide #1 on 12/21/23 at 10:23 AM the NA confirmed she had shaved Resident #10 one day last week before she got him up that morning. The NA stated she thought the Resident looked like he had not been shaved for a few days and thought she would shave him while she had the time. She stated she was not aware that Resident #10 was not supposed to be shaved. The NA stated she did not notice the signs posted in his room until she went into his bathroom to put the razor away, but she had already shaved him. The NA explained she had worked with Resident #10 before but had never paid attention to the signs posted in his room. On 12/21/23 at 3:46 PM during an interview with the Administrator stated the NA did not shave him with malicious intent, but she thought she was doing him a service.

Based on record reviews and interviews the facility failed to ensure the code status information was accurate throughout the medical record for 2 of 2 residents reviewed for advanced directives (Resident #47 and Resident #53). The findings included: 1. Resident #47 was admitted to the facility on [DATE]. A review of the code status notebook maintained at the nursing station on [DATE] at 11:05 AM revealed a yellow golden rod code status of Do Not Resuscitate (DNR) dated [DATE]. Resident #47's quarterly Minimum Data Set assessment dated [DATE] revealed his cognition was severely impaired. A review of Resident #47's medical record on [DATE] at 11:05 AM revealed an advanced directive status of Cardiopulmonary Resuscitation (CPR). On [DATE] at 11:30 AM an interview was conducted with Nurse #1 who explained the residents' code status was maintained in their electronic medical record under their picture on their profile screen. The Nurse also stated their code status was also maintained in the code status notebook which was kept at the nurses' station on the unit. The Nurse reported the medical record on the computer was the most accurate because that was where the changes were made first before the code status notebook. An interview was conducted with Nurse Supervisor #1 on [DATE] at 11:43 AM. The Supervisor explained that the advanced directives were handled during the admission process and the desired code status was documented on the resident's face sheet in the computer and notation such as the DNR paperwork was placed in the code status notebook at the nurses' station. The Supervisor stated medical records was responsible for auditing the code status directives to make sure they matched. During an interview with the Director of Nursing (DON) on [DATE] at 12:10 PM the DON explained that nursing was responsible for putting the residents' code status in the code status notebook at the nurses' station and medical records was responsible for making sure the code status was correct in the electronic medical record. She stated medical records was responsible for ensuring the two places matched. On [DATE] at 12:25 PM an interview was conducted with Medical Records personnel who explained that she made sure the paperwork and orders pertaining to the residents' advance directives were signed and dated in the electronic health record and made sure the DNR forms were put in the code status notebooks which were maintained at the nurses' desk. The Medical Records staff continued to explain that sometimes the doctors will change the residents' advanced directive during their rounds and will put the code status paperwork in the code status notebooks thinking they were helping out and she thought that was why there was a discrepancy in Resident #47's advanced directive. During an interview with the Administrator on [DATE] at 3:37 PM he explained that the reason for the discrepancy in Resident #47's advanced directive status was because of human error. He stated regardless of what the electronic health record indicated the nurses knew to go by the forms in the code status notebook at the nurses' desk. 2. Resident #53 was admitted to the facility on [DATE]. A review of the code status notebook maintained at the nursing station on [DATE] at 11:05 AM revealed a yellow golden rod code status of Do Not Resuscitate (DNR) dated [DATE]. Resident #53's quarterly Minimum Data Set assessment dated [DATE] revealed his cognition was moderately impaired. A review of Resident #53's medical record on [DATE] at 11:05 AM revealed an advanced directive status of Cardiopulmonary Resuscitation (CPR). On [DATE] at 11:30 AM an interview was conducted with Nurse #1 who explained the residents' code status was maintained in their electronic medical record under their picture on their profile screen. The Nurse also stated their code status was also maintained in the code status notebook which was kept at the nurses' station on the unit. The Nurse reported the medical record on the computer was the most accurate because that was where the changes were made first before the code status notebook. An interview was conducted with Nurse Supervisor #1 on [DATE] at 11:43 AM. The Supervisor explained that the advanced directives were handled during the admission process and the desired code status was documented on the resident's face sheet in the computer and notation such as the DNR paperwork was placed in the code status notebook at the nurses' station. The Supervisor stated medical records was responsible for auditing the code status directives to make sure they matched. During an interview with the Director of Nursing (DON) on [DATE] at 12:10 PM the DON explained that nursing was responsible for putting the residents' code status in the code status notebook at the nurses' station and medical records was responsible for making sure the code status was correct in the electronic medical record. She stated medical records was responsible for ensuring the two places matched. On [DATE] at 12:25 PM an interview was conducted with Medical Records personnel who explained that she made sure the paperwork and orders pertaining to the residents' advance directives were signed and dated in the electronic health record and made sure the DNR forms were put in the code status notebooks which were maintained at the nurses' desk. The Medical Records staff continued to explain that sometimes the doctors will change the residents' advanced directive during their rounds and will put the code status paperwork in the code status notebooks thinking they were helping out and she thought that was why there was a discrepancy in Resident #53's advanced directive. During an interview with the Administrator on [DATE] at 3:37 PM he explained that the reason for the discrepancy in Resident #53's advanced directive status was because of human error. He stated regardless of what the electronic health record indicated the nurses knew to go by the forms in the code status notebook at the nurses' desk.

Based on record review and interviews with staff the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A services for 1 of 3 residents reviewed for Beneficiary Notification (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE]. Review of the beneficiary notifications for Resident #10 revealed a Notice of Medicare Non-Coverage (NOMNC) was signed by Responsible Party (RP) on 11/06/23. The NOMNC showed the facility initiated Resident #10 be discharged from skilled rehab therapy on 11/09/23 due to no further progress. The facility was unable to provide evidence a SNF-ABN was provided to Resident #10 or the RP. Review of the beneficiary notification of residents discharged within the last six months revealed Resident #10 was discharged from Medicare Part A on 11/09/23 with remaining benefit days. Resident #10 remained as a resident in the facility. During an interview on 12/19/23 at 12:24 PM the Administrator explained the Social Worker (SW) was responsible for providing the NOMNC and SNF-ABN forms. He explained if Resident #10 or his RP did not receive the SNF-ABN form, it was as an oversight made by the SW. An interview was conducted with SW on 12/21/23 at 12:35 PM. The SW confirmed she was responsible for providing residents with the ABN-SNF form. She explained therapy gave her 5 to 7 days' notice when a resident was close to discharge, and she would check their insurance. For residents who remained in the facility with Medicare Part A and benefit days remaining, she issued both the NOMNC and SNF-ABN forms. The SW stated Resident #10, or his RP did not get the ABN-SNF was an oversight on her part, and considered the mistake was due to human error.

Based on record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change had occurred for 2 of 9 sampled residents reviewed for hospice and resident assessments (Residents #28 and #47). Findings included: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses that included other neurological conditions and malnutrition. Review of Resident #36's electronic medical record revealed a significant change MDS assessment with an Assessment Reference Date (ARD) of 11/09/23. The MDS assessment was signed as completed on 12/14/23 which was 36 days after the facility determined Resident #28 had a significant change in status. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #28's significant change MDS assessment dated [DATE] was late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 37280 2. Resident # 47 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. Review of Resident #47's medical record revealed an order for Hospice services related to dementia and weight loss dated 06/08/23. Review of Resident #47's significant change Minimum Data Set assessment for the election of Hospice services was dated 06/24/23. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 12/21/23 at 12:20 PM. The Coordinator explained that the significant change MDS had to be completed within 14 days of the election of Hospice services then acknowledged the assessment was completed 2 days passed the 14-day timeframe. The Coordinator explained that due to the recent changes in the Resident Assessment Instrument (RAI) process and the number of assessments required she was behind on multiple assessments. An interview was conducted with the Administrator on 12/21/23 at 3:40 PM. The Administrator explained that he was aware of the MDS assessments were not being completed in time and stated he felt the breakdown was due to the increase in the MDS Coordinator's workload because of the recent changes to the RAI guidelines.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set Assessments (MDS) in the areas of Preadmission Screening and Resident Review (PASRR) and hospice for 2 of 4 residents reviewed for PASRR and hospice (Residents #6 and #18). Findings included: 1. A PASRR Level II Determination Notification letter dated 05/17/22 for Resident #6 had an expiration date of 06/16/22. It was noted nursing facility placement was appropriate for a limited nursing facility stay lasting no more than 30 calendar days. Resident #6 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation and depression. The annual MDS assessment dated [DATE] indicated Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 12/18/23 revealed Resident #6 had a 30-day [NAME] II PASRR effective 05/17/22 with an expiration date of 06/16/22. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator explained she did not realize Resident #6's PASRR number was considered to be a Level II PASRR determination which was why his annual MDS assessment dated [DATE] did not accurately reflect his Level II PASRR status. During an interview on 12/19/23 at 5:11 PM, the Administrator explained the MDS Coordinator was behind on completing MDS assessments and he felt the reason Resident #6's MDS assessment did not accurately reflect his Level II PASRR status was an oversight due to the MDS Coordinator rushing to get MDS assessments completed. 2. Resident #18 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease and chronic kidney disease with heart failure. Review of Resident #18's Hospice care plan initiated on 10/20/22 revealed in part she had a terminal prognosis for which she had elected hospice services. The Hospice Recertification dated 10/18/23 revealed Resident #18 elected to receive hospice services effective 10/20/22. The annual MDS dated [DATE] did not indicate Resident #18 was receiving hospice care. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator confirmed Resident #18 was receiving hospice care effective 10/20/22. The MDS Coordinator explained she had correctly coded Resident #18's prognosis on the MDS assessment but forgot to code she also received hospice care and stated it was an oversight. During an interview on 12/19/23 at 5:11 PM, the Administrator explained the MDS Coordinator was behind on completing MDS assessments and he felt the reason Resident #18's MDS assessment did not accurately reflect she received hospice care was an oversight due to the MDS Coordinator rushing to get MDS assessments completed.

Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 2 sampled residents reviewed for PASRR (Resident #6). Findings included: A PASRR Level II Determination Notification letter dated 05/17/22 for Resident #6 had an expiration date of 06/16/22. It was noted nursing facility placement was appropriate for a limited nursing facility stay lasting no more than 30 calendar days. Resident #6 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation and depression. The annual MDS assessment dated [DATE] indicated Resident #6 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 12/18/23 revealed Resident #6 had a 30-day [NAME] II PASRR effective 05/17/22 with an expiration date of 06/16/22. Further review revealed no evidence a PASRR evaluation was requested or a new PASRR had been obtained. During an interview on 12/19/23 at 5:11 PM, the Administrator explained there was no one person responsible for submitting PASRR reevaluation requests as it was an Interdisciplinary Team effort. The Administrator stated he was not sure what happened or why a PASRR evaluation request was not requested prior to Resident #6's PASRR expiration date. The Administrator explained they realized it was an issue when reviewing Resident #6's PASRR information on 12/18/23 and a request for reevaluation was submitted.

Based on record review and staff interviews, the facility failed to refer residents who were admitted with mental health disorders for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination of specialized services for 1 of 2 residents reviewed for PASRR (Residents #57). The findings included: A PASRR Determination Notification letter dated 07/31/23 revealed Resident #57 had a Level I PASRR with no expiration date. Resident #57 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, delusional disorder, and bi-polar disorder. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #57 received antipsychotics on a routine basis during the MDS assessment period. The psychotropic drug use Care Area Assessment (CAA) associated with the admission MDS assessment dated [DATE] revealed in part, Resident #57 had a diagnosis of bipolar disorder and received antipsychotic medications. She was seen by the Psychiatrist on 08/04/23 for evaluation of mania and adjustments were made to her medications. It was noted that a care plan would be developed for medication use and side effects. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 12/18/23 revealed Resident #57 had a Level I PASRR effective 07/31/23. There were no requests for a Level II PASRR evaluation submitted or completed since 07/31/23. During an interview on 12/19/23 at 5:11 PM, the Administrator explained the current process for submitting PASRR reevaluation reviews was an Interdisciplinary Team effort and he was not sure who should be responsible for submitting PASRR Level II evaluation requests when a resident was admitted with mental health disorders and had a Level I PASRR determination. The Administrator explained the facility usually went by the PASRR information submitted by the hospital with the assumption the hospital had requested a Level II PASRR evaluation when indicated. He stated he now realized they could do better with their process for following-up on a resident's PASRR when a resident was admitted to the facility with mental health disorders.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 sampled residents whose closed records were reviewed (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses that included acute (severe and sudden onset) nondisplaced (bone cracks or breaks but maintains proper alignment) S2/S3 (referring to a sacrum fracture), severed L4-5 (referring to lumbar fracture), and severe, chronic L5 compression (type of fracture or break in the bones that make up the spine) fracture. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #65 had intact cognition. She required supervision with eating and locomotion off the unit and extensive staff assistance with all other activities of daily living (ADL). She received scheduled and as needed pain medication and reported a pain level of 09 out of 10 (numerical pain rating scale with 10 being the worst possible pain) that affected day-to-day function. The ADL Care Area Assessment (CAA) associated with the admission MDS dated [DATE] revealed in part, Resident #65 required assistance with all ADL due to limited mobility. She admitted with a urinary tract infection (UTI), had fractures of the sacrum and fifth lumbar vertebrae and additional diagnoses of spinal stenosis, hypertension, gastrointestinal reflux disease, macular degeneration, weakness, and history of falling. She was working with therapy for strength and mobility, however, limited due to poor pain control and was able to eat independently with tray set-up. It was noted a care plan would be developed for staff assistance and improved self-care. The pain CAA associated with the admission MDS dated [DATE] revealed in part, Resident #65 was having a difficult time with pain control and preferred to lay flat in bed to relieve pain which was interfering with therapy for strength and mobility. It was noted a care plan would be developed for assessment of pain and possible interventions to improve pain relief. The fall CAA associated with the admission MDS dated [DATE] revealed in part, Resident #65 had a fall prior to admission, none since admission, and a care plan would be developed for risk of fall with injury due to weakness, pain, and limited mobility. Review of Resident #65's comprehensive care plan on 12/20/23 revealed a discharge planning care plan initiated on 08/19/23 and a nutritional care plan initiated on 09/01/23. There were no other care plans developed. During an interview on 12/21/23 at 12:50 PM, the MDS Coordinator confirmed she was the MDS Coordinator at the time of Resident #65's admission to the facility and was the one who normally completed comprehensive care plans for residents. The MDS Coordinator reviewed Resident #65's care plan and stated she would not consider it to be comprehensive or complete. The MDS Coordinator explained she had only been employed for a year and it took her some time to learn the facility's system which may have been the reason Resident #65's comprehensive care plan was not developed. During an interview on 12/21/23 at 12:58 PM, the Administrator stated it was his expectation that comprehensive care plans would be developed within the regulatory timeframe.

Based on observations, record reviews and resident and staff interviews the facility failed to post cautionary and safety signs that indicated the use of oxygen for 2 of 2 residents reviewed for respiratory care (Resident #3 and Resident # 48). The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease. A review of Resident #3's physician orders dated 05/11/23 revealed oxygen at 2-5 liters per minute via nasal cannula to maintain oxygen saturation above 90%. An interview and observation made with Resident #3 on 12/18/23 at 10:44 AM revealed the Resident lying in bed wearing a nasal cannula with oxygen being delivered at 3 liters per minute. The Resident explained she wore oxygen all the time. Observations made 12/18/23 at 10:44 AM and 12/19/23 at 3:09 PM revealed there was no warning sign posted on the outside of Resident #3's door to indicate oxygen was in use. On 12/20/23 at 11:25 AM an interview was conducted with Nurse #1 who explained the person who initiates the oxygen should post the oxygen in use signs on the resident's door. An interview conducted with Nurse Supervisor #1 on 12/20/23 at 11:33 AM. The Supervisor explained that the oxygen set up was prepared before the resident was admitted to the facility which included the red no smoking oxygen in use signs posted on the doorframes. An interview conducted with the Director of Nursing (DON) on 12/20/23 at 12:01 PM revealed the oxygen in use signs should be posted on the doorframe of all rooms that had oxygen in use in them. The DON stated the nurses should be checking the doors for the oxygen signs when they made rounds. During an interview with the Administrator on 12/21/23 at 3:26 PM the Administrator explained that he had already been made aware that the oxygen signs were not posted on some of the doors of the residents who received oxygen. He indicated his expectation was that nursing be responsible for posting the oxygen in use signs on the residents' doors that receive oxygen. 37538 2. Resident #48 was admitted to the facility on [DATE]. Resident #48's diagnoses included dementia and chronic obstructive pulmonary disease (COPD). Review of the active physician orders included Resident #48 received continuous oxygen at a rate of 2 liters per minute (LPM) as needed and continuous oxygen at 2 LPM twice daily when working with therapy for hypoxia (low levels of oxygen in the body's tissues). During an observation made on 12/19/23 at 9:24 AM, Resident #48 was sitting in his room in his wheelchair wearing oxygen via nasal cannula set at 2 liters per minute. There was no warning sign posted on the outside of the entry door to indicate oxygen was in use in the room of Resident #48. During an interview on 12/20/23 at 11:25 AM Nurse #1 explained she occasionally was the assigned nurse for Resident #48. She revealed the person who initiates oxygen should post the oxygen in use signs on the resident's door. During an interview on 12/20/23 at 11:33 AM Nurse Supervisor #1 explained the setup for oxygen included to post the red no smoking oxygen in use sign on the doorframe entering the resident's room. An interview conducted with the Director of Nursing (DON) on 12/20/23 at 12:01 PM revealed the warning signs should be posted on the doorframe of all rooms with oxygen in use. The DON stated the nurses should be checking the doors for oxygen signs when they make rounds. During an interview on 12/21/23 at 3:26 PM the Administrator revealed he was made aware the warning signs oxygen in use were not posted on some of the doors of the residents who received oxygen. He indicated his expectation was that nursing be responsible for posting the oxygen in use signs on the residents' doors that receive oxygen.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 04/09/21 and 08/26/22. This was for a repeat deficiency for failure to provide beneficiary notice originally cited on 04/09/21 and subsequently recited on the annual recertification survey conducted on 12/21/23. The repeat deficiency for failure to develop and implement a comprehensive care plan was originally cited during the recertification and complaint survey conducted on 08/26/22 and subsequently recited on the annual recertification survey conducted on 12/21/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: The tags were cross referenced to: F582- Based on record review and interviews with staff the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A services for 1 of 3 residents reviewed for Beneficiary Notification (Resident #10). During the recertification and complaint survey conducted on 04/09/21, the facility failed to provide the Centers for Medicare and Medicaid Services Skilled Nursing Facility Advanced Beneficiary Notice (form CMS-10055 SNF ABN) prior to a resident's discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary notification. F656- Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 sampled residents whose closed records were reviewed (Resident #65). During the recertification and complaint survey conducted on 08/26/22 the facility failed to develop a care plan for hospice care and anticoagulation medication use for 1 of 5 residents reviewed for unnecessary medications. During an interview on 12/21/23 at 5:15 PM the Administrator revealed monthly meetings were held to review quality measures and identify trends and audits were completed and modified as needed. He stated the change in leadership and the MDS Coordinator and the new MDS requirements played a role in the repeat of deficiencies. He explained there were issues with the software the facility used that caused the submission of MDS assessments to be rejected and not completed timely that could impact the resident's care plan. For the issuance of the SNF-ABN forms those were overlooked and not included in the review to ensure the Notice of Medicare Non-Coverage (NOMNC) was issued timely.

Based on record review and interviews with the resident and staff the facility failed to offer and administer the influenza vaccine for 1 of 5 residents reviewed for immunizations (Resident #5). Findings included: Review of the facility's policy for resident immunizations revised 11/2017 read in part, The Director of Nursing (DON) will be responsible for ensuring residents receive immunizations. On admission the facility will request information on previous immunizations and the Medical Records Coordinator and will notify the DON or designee of the history. Prior to immunization, the resident or their legal representative will be provided information and education regarding the benefits and potential side effects of the influenza immunization. Receipt of education and refusal of vaccination will be documented in the medical record. All residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident was already immunized. If immunization is provided in the facility the following information will be documented in the resident's medical record: site of administration; date of administration; manufacturer and lot number of the vaccine; expiration date; and name of the person administering the vaccine. Resident #5 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (low oxygen levels). Review of the medical records for Resident #5 revealed she was listed as her own Responsible Party (RP). Review of the immunizations record revealed Resident #5 signed consent to receive the covid-19 booster vaccine and it was administered on 07/06/23. There was no consent or declination documentation to support the facility provided education for the influenza vaccine for 2023. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #5 cognition was assessed as intact, and the influenza vaccine was not given and was not offered. During an interview on 12/21/23 at 3:46 PM the Director of Nursing (DON) revealed she was the Infection Preventionist, and it was joint effort to ensure consent for immunizations were offered to residents. She explained the process was for the Medical Records Coordinator to obtain consent upon admission and the assigned nurse to administer the vaccine and document it was given on the resident's Medication Administration Record and record the lot number and expiration date on the consent form and signed it. A follow up interview was conducted with the DON/Infection Preventionist on 12/21/23 at 4:40 PM. The DON was unable to provide documentation to show Resident #5 received education, either gave consent, or declined the influenza vaccine on admission to the facility. The DON explained Resident #5's family member was asked to sign consent for Resident #5 to receive the influenza vaccine when the facility started the annual vaccinations in October 2023 but refused stating Resident # 5 was able to sign for consent herself. The DON confirmed Resident #5 was able to make her own healthcare decisions and when the family member did not sign consent for the influenza vaccine there was no follow up with Resident #5 and it was missed. The DON stated Resident #5 received the pneumococcal vaccine prior to admission and was up to date. An interview was conducted on 12/21/23 at 4:54 PM with Resident #5. Resident #5 revealed the facility did not offer her the influenza vaccine until today (12/21/23). Resident #5 revealed she was provided education that discussed the benefits of being immunized and on 12/21/23 she chose to and did receive the influenza vaccine. During an interview on 12/21/23 at 5:06 PM the Administrator stated consent and declination forms for immunizations should be followed up on by the nurse and the DON who was also the Infection Preventionist.

Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 1 of 9 residents reviewed for resident assessments (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's electronic health record revealed an annual MDS assessment with an ARD of 08/10/23 was marked as completed on 09/08/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #2's annual MDS assessment dated [DATE] was late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the observation period) for 7 of 9 residents reviewed for resident assessments (Residents #2, #6, #16, #20, #28, #48, and #52). Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Electronic Health Record (EHR) on 12/19/23 at 3:55 PM revealed the following: a. A quarterly MDS assessment with an ARD of 08/10/23 was marked as complete on 09/08/23. b. A quarterly MDS assessment with an ARD of 11/10/23 with no date of completion. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator explained Resident #2's quarterly MDS assessment dated [DATE] was completed late and the MDS assessment dated [DATE] had not yet been done. She confirmed both assessments were not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 2. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's Electronic Health Record (EHR) on 12/19/23 at 4:00 PM revealed the following: a. A quarterly MDS assessment with an ARD of 08/10/23 was marked as complete on 09/02/23. b. A quarterly MDS assessment with an ARD of 11/10/23 was marked as complete on 12/17/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #6's quarterly MDS assessments dated 08/10/23 and 11/10/23 were completed late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 3. Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's Electronic Health Record (EHR) on 12/19/23 at 4:05 PM revealed a quarterly MDS assessment with an ARD of 11/13/23 with no date of completion. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #16's quarterly MDS assessment dated [DATE] has not yet been done and was late. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 4. Resident #20 was admitted to the facility on [DATE]. Review of Resident #20's Electronic Health Record (EHR) on 12/19/23 at 4:10 PM revealed a quarterly MDS assessment with an ARD of 11/09/23 that was marked as complete on 12/15/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #20's quarterly MDS assessment dated [DATE] was completed late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 5. Resident #28 was admitted to the facility on [DATE]. Review of Resident #28's Electronic Health Record (EHR) on 12/19/23 at 4:15 PM revealed a quarterly MDS assessment with an ARD of 08/15/23 that was marked as complete on 09/04/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #28's quarterly MDS assessment dated [DATE] was completed late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 6. Resident #48 was admitted to the facility on [DATE]. Review of Resident #48's Electronic Health Record (EHR) on 12/19/23 at 4:20 PM revealed the following: a. A quarterly MDS assessment with an ARD of 08/22/23 was marked as complete on 09/06/23. b. A quarterly MDS assessment with an ARD of 11/22/23 with no date of completion. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator explained Resident #48's quarterly MDS assessment dated [DATE] was completed late and the MDS assessment dated [DATE] had not yet been done. She confirmed both assessments were not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines. 7. Resident #52 was admitted to the facility 02/01/23. Review of Resident #52's Electronic Health Record (EHR) on 12/19/23 at 4:25 PM revealed the following: a. A quarterly MDS assessment with an ARD of 08/10/23 was marked as complete on 08/31/23. b. A quarterly MDS assessment with an ARD of 11/10/23 was marked as complete on 12/17/23. During an interview on 12/19/23 at 4:35 PM, the MDS Coordinator revealed she was currently behind on completing MDS assessments. The MDS Coordinator confirmed Resident #52's quarterly MDS assessments dated 08/10/23 and 11/10/23 were completed late and not completed within the regulatory timeframe. During an interview on 12/19/23 at 5:11 PM, the Administrator revealed he was aware MDS assessments were not being completed timely. He explained the issue with MDS assessments being late was identified 11/27/23 and a Performance Improvement Plan (PIP) was in process. The Administrator stated he felt the breakdown was due to the increase in the MDS Coordinator's workload as a result of the recent changes to the Resident Assessment Instrument (RAI) guidelines.

Based on record review and staff interviews, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines by not testing residents and staff immediately in response to a staff member testing positive for COVID-19. The facility also failed to document COVID-19 test results in the residents' medical record for 3 of 3 residents reviewed (Resident #4, Resident #11, and Resident #25). These failures occurred during a COVID-19 pandemic. Findings included: 1. The CDC guidance related to New Infection in Healthcare Personnel (HCP) or Residents last updated 02/02/22, read in part, Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or nursing home resident should be evaluated as a potential outbreak. Perform contact tracing to identify any HCP who have had a higher-risk exposure or residents who may have had close contact with the individual with [CONDITION(S)]-Cov-2 infection, all HCP who have had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested as described in the testing section. If the facility does not have the expertise, resources, or ability to identify all close contacts they should instead investigate the outbreak at a facility-level or group-level: perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after exposure, if known) and, if negative, again 5 to 7 days later. The facility's resident and staff COVID-19 testing spreadsheet revealed Dietary Aide #1 tested positive for COVID-19 on 07/12/22. Further review revealed the following: · Facility wide testing of all residents and staff was conducted on 07/14/22 to 07/15/22 with Dietary Aide #2 testing positive on 07/16/22 and Housekeeping Aide #1 testing positive on 07/17/22. No residents tested positive. · Facility wide testing of all residents and staff was conducted on 07/18/22 to 07/19/22 with Housekeeping Aide #2 testing positive on 07/19/22. No residents tested positive. · Facility wide testing of all residents and staff was conducted on 07/21/22 to 07/22/22 with the Environmental Services Team Leader #1 testing positive on 07/21/22 and Resident #44 testing positive on 07/22/22. · Facility wide testing of all residents and staff was conducted on 07/25/22 and 07/26/22 with no new positive cases. · Facility wide testing of all residents and staff was conducted on 07/28//22 and 07/29/22 with no new positive cases. During an interview on 08/23/22 at 4:04 PM, the Administrator explained due to the county transmission rate, they had been testing all non-vaccinated or up-to-date employees twice weekly on Tuesday and Fridays. If an employee tested positive and they identified no direct contact with residents, then they were informed by the Local Health Department they could wait until the next scheduled testing date to conduct facility-wide testing of residents and staff. The Administrator stated an outbreak started on 07/12/22 when Dietary Aide #1 developed symptoms of congestion and a runny nose and tested positive for COVID-19. He explained Dietary Aide #1 worked in the kitchen as a dishwasher and assisted with meal tray preparation during resident meal service but had no close contact with residents, wore Personal Protective Equipment (PPE) consistently and remained socially distanced. He added based on the guidance they received from the Local Health Department, they were ok to wait until the next scheduled testing date on 07/15/22 to test other residents and staff. During follow-up interviews on 08/25/22 at 3:33 PM and 08/26/22 at 8:45 AM, the Administrator confirmed they did not perform COVID testing on the dietary staff members who had worked with Dietary Aide #1 on 07/12/22 as part of their contact tracing. The Administrator stated the CDC guidance for New Infection in Healthcare Personnel (HCP) or Residents last updated 02/02/22, indicated when performing an outbreak to a known case, facilities should always refer to the recommendation of the jurisdictions public health authority. He explained they had followed the guidance they received from the Local Health Department and restated they were informed they could wait until the next scheduled testing date on 07/15/22 to test other residents and staff. The Administrator added he felt they had met the regulation requirements for testing based on their interpretation and guidance received from the Local Health Department. 2. The facility's resident and staff COVID-19 testing spreadsheet provided by the Administrator revealed in response to a staff member testing positive for COVID-19 on 07/12/22, all residents and staff were tested on the following dates: 07/14/22 to 07/15/22, 07/18/22 to 07/19/22, 07/21/22 to 07/22/22, 07/25/22 to 07/26/22, 07/28/22 to 07/29/22. a. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's medical record revealed no COVID test results for the month of July 2022. b. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interviews on 08/26/22 at 8:45 AM and 10:49 AM, the Administrator confirmed residents' COVID-19 negative rapid test results were not currently documented in their medical record. He explained positive test results were documented in the resident's medical record and negative test results were documented on the facility's COVID-19 testing spreadsheet/log. The Administrator stated he had no explanation as to why they did not document the negative test results in the resident's medical record but he would have staff work on getting the information entered.

Based on observations, record review and Physician and staff interviews, the facility failed to prevent a cognitively impaired resident with known wandering and exiting seeking behaviors from exiting the facility unsupervised and remaining outside in weather temperature of 14 degrees Fahrenheit, without staff knowledge, increasing the likelihood for hypothermia (low body temperature) to develop for 1 of 3 residents reviewed for accidents (Resident #4). The findings included: Resident #4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with behavioral disturbance. The Minimum Data Set (MDS) dated [DATE] assessed Resident #4 with severe impairment in cognition for daily decision making. He required limited assistance with locomotion on and off the unit, had no wandering episodes during the MDS assessment period and used a walker and wheelchair for mobility. A care plan initiated 10/22/20 noted Resident #4 was at risk for elopement due to confusion, wandering and exit-seeking behaviors. The goal was he would not leave the facility unattended through the next review. Interventions included: place elopement device on resident, re-orient to person and family while redirecting as needed, distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, and books. Review of the staff progress notes related to Resident #4's wandering revealed the following entries: · 12/16/20 3:27 PM read in part, resident does talk about leaving the building, reoriented and encouraged not to leave the building unassisted. Wears elopement device. · 12/19/20 3:43 PM read in part, resident found in back service hall at the back door. Redirected to room without difficulty, resident wearing elopement device that is working properly. · 12/22/20 1:09 AM read in part, resident stated he wanted to go home. Redirected him to understand that he needed to stay in the building. No acute behaviors noted. Continue to monitor. · 12/22/20 8:39 PM read in part, resident was exit seeking all afternoon. Was redirected back to his room several times. Will continue to monitor. A staff progress note dated 12/25/20 at 11:01 PM written by Nurse #1, read in part, Resident #4 found outside building behind C Hall corridor at 8:15 PM. Resident unable to get back into building. Resident brought back in and assessed. Covered resident with heated blankets and administered warm beverage. Resident refused pain meds. Skin warm, dry and fragile, no discoloration to upper and lower extremities. A staff progress note dated 12/26/20 at 3:07 AM written by Nurse #1, read in part, found nurse at end of C-Hall outside pounding on door with Resident #4 standing beside her with walker. At 8:10 PM, Resident #4 was assessed and swaddled in heated blankets and towels. Vitals were as follows: temperature 97.7 degrees, pulse 72, respiration 16, oxygen saturation 97 percent on room air, and blood pressure 117/59. Skin warm, dry and fragile. Staff have checked on Resident #4 every hour this shift, resting in bed in room with eyes closed. Review of the December 2020 Secure Care Nightly Checklist for elopement device functioning noted Resident #4's was checked nightly with no concerns identified. Resident #4's elopement device was initialed as checked and functioning on 12/24/20 with no time noted when the check was completed. An online website named Custom Weather was used to obtain the outside weather in the Asheville area on 12/25/20 and noted at 6:54 PM the temperature was 15 degrees Fahrenheit with wind speeds of 6 miles per hour (mph). At 7:54 PM the temperature was 14 degrees Fahrenheit with wind speeds of 6 mph. A physician's progress note dated 12/26/20 read in part, left building last night in two coats and a hat at about 8:00 PM. He was out for more than 20 minutes but less than 40 minutes. He did have his wanderguard on. When Nurse #2 found him, he had no evidence of hypothermia. There were no ramifications from his going outside. He did have some confusion above his baseline last night and this AM. During a telephone interview on 04/01/21 at 1:25 PM, Nurse #2 confirmed she was working 6:00 PM to 6:00 AM on 12/25/20 when she found Resident #4 standing at the exit door, outside the building. Nurse #2 was unable to recall the exact time she found Resident #4 but stated it would have been between 8:00 PM and 9:00 PM when Pharmacy usually delivered. She explained when she went to the front entrance to meet Pharmacy, she forgot her badge and wasn't able to get back into the building. Nurse #2 added she rang the buzzer for several minutes and then decided to walk around the outside of the building to see if she could get Nurse #1's attention on C-Hall. As she rounded the corner of the building at the bottom of the parking lot, Nurse #2 stated she saw someone standing at the C-Hall exit door and the closer she got, she realized it was Resident #4. Nurse #2 recalled Resident #4 stating he couldn't get back in and when she started pounding on the door, Nurse #1 responded quickly and let them both back in the facility. She added Nurse #1 assisted Resident #4 back to his room for assessment and wrapped him with warm blankets. Nurse #2 explained the alarm to the exit door normally sounded when the door was opened; however, it had not sounded that evening when opened by Resident #4. During a telephone interview on 03/31/21 at 10:09 AM, Nurse #1 confirmed she was the nurse assigned to provide care to Resident #4 during the hours of 6:00 PM to 6:00 AM on 12/25/20. Nurse #1 recalled at around 8:00 PM, she in a room assisting another resident when she heard pounding on the exit door at the end of the C-Hall and when she stepped out to investigate, she noticed Nurse #2 and Resident #4 standing outside the exit door. Nurse #1 was unaware that Resident #4 had gotten out of the building and stated the best she could recall, she had last seen him when she went to his room at approximately 6:40 PM. Nurse #2 stated they assisted him back to his room, wrapped him in warm blankets and completed a skin assessment which revealed his skin was pinkish red and vitals were stable. Nurse #1 stated Resident #4 had an elopement device in place on his ankle that was checked each shift and functioning but when he opened the exit door, the alarm never went off. She added normally they would also receive an automated phone call alerting them the name of the resident and their location but they never received a phone call. Nurse #1 notified the Director of Nursing and the on-call physician of the elopement. She did not recall any interventions put into place that evening other than conducting safety checks on Resident #4 every hour the remainder of the night. During a follow-up telephone interview on 03/31/21 at 7:01 PM, Nurse #1 confirmed Resident #4 was wearing his elopement device, 2 coats, socks and shoes when he exited the building on 12/25/20. Nurse #1 explained elopement devices were checked diligently every night; however, there was no set time as to when the check was to be completed, some nurses checked them during medication pass while others might check the functioning later in the shift after finishing their charting. Nurse #1 added Resident #4's elopement device was last checked on 12/24/20 before he exited the facility on 12/25/20 and she checked it again after they had found him outside the building and it was functioning. She could not recall Resident #4 exhibiting any behavior out of the ordinary that evening and stated he had a history of wandering into other resident rooms but she had not known him to attempt to open the exit doors of the facility. During a telephone interview on 03/31/21 at 1:24 PM, Nurse Aide (NA) #1 confirmed she worked 6:00 PM to 6:00 AM on 12/25/20 and was assigned to provide care to Resident #4. NA #1 recalled being notified by Nurse #1 that Resident #4 was found outside the building. NA #1 stated she was not aware he had gotten out of the building and explained typically the alarm would sound to alert staff but it had not gone off that evening when Resident #4 opened the exit door. NA #1 added Resident #4 had the tendency to wander out into the hall but had never tried to exit the building before. She recalled seeing Resident #4 in his room during first rounds but could not recall the exact time. During an interview on 03/31/21 at 10:55 AM, the Director of Nursing (DON) recalled being notified by Nurse #1 that Resident #4 exited the building on 12/25/20. The DON explained Nurse #2 had gone to the front door of the facility to meet Pharmacy but forgot her badge and couldn't get back into the building, so she walked around the building to the C-Hall exit door to get the attention of Nurse #1 to let her back in when she found Resident #4 standing outside on the sidewalk just a few feet to the right of the exit door and brought him back into the building. The DON instructed Nurse #1 to assess Resident #4 for hypothermia and the physician assessed him on 12/26/20. During interviews on 03/31/21 at 12:03 PM and 3:36 PM, the Administrator stated he was notified on 12/25/20 that Resident #4 was found outside the building at approximately 8:00 or 9:00 PM. The Administrator stated when he reviewed the video footage from 12/25/20, Resident #4 went to the exit door at the end of C-Hall at 7:23 PM, pushed the door handle and walked outside the door to the sidewalk. The video footage also showed Resident #4 immediately turned back around to go back in the facility but couldn't get in the door and was later found by Nurse #2 by the exit door, brought back into the building at 8:15 PM and assessed by Nurse #1. The Administrator stated Resident #4 was placed on 30 minute visual checks throughout the remainder of the evening and the next day, 12/26/20, he was evaluated by the physician with no adverse effects identified. The Administrator stated staff were also instructed to visually check the hallway exit door throughout the remainder of the evening on 12/25/20 to ensure it was functioning and recalled seeing the log where staff had checked but he was unable to locate the documentation. A root cause analysis was completed and determined somehow the exit door had been put in override mode for the exit door to open freely without alarming, which the Administrator stated should have not happened, and was immediately fixed. The Administrator explained they put a Performance Improvement Plan (PIP) in place on 12/26/20 for elopement prevention which included staff education, an added sensor placed on the exit door so when the door handle was pushed and the delayed egress (locking system to prevent a door from opening immediately) opened the door lock, he and the Facilities Maintenance Director (FMD) now receive a call within 10 seconds to let them know the door was opened, and the panel to the exit door was reprogrammed with a new override code that only the Administrator and FMD have. The Administrator verified education was provided to staff the end of December 2020 and stated he knew they had discussed elopement but it was right in the midst of a facility-wide COVID outbreak and he couldn't locate any documentation of the staff training provided. Since then, the Administrator reported there had not been any issues with the alarm on the C-Hall exit door not working. During an interview on 04/01/21 at 2:50 PM, the Facilities Maintenance Director (FMD) reported he conducted weekly checks of the 4 facility exit doors with delayed egress to ensure they were functioning properly which included holding the door handle for 15 seconds to make sure the alarm sounded when opened and when the door was reset, it was secure. The FMD stated he was not at the facility on 12/26/20 but was told about the incident that happened on 12/25/20 with Resident #4 and they could not determine how the exit door was placed into override mode allowing the exit door to open without alarming. He added the C-Hall exit door was the only one in the facility that had both delayed egress and elopement device locking systems. The FMD explained the facility had since installed an audible strobe light alarm system at the nurses' station to alert them when the door was opened. He added the egress panel was set at 15 seconds that started counting down when the door handle was pushed and when it reached 12 seconds, the audible alarm at the nurses' station would sound, giving staff a head start to reach the door before the panel reached zero and the exit door opened. During a telephone interview on 04/01/21 at 4:46 PM, the Physician confirmed she evaluated Resident #4 on 12/26/20 and upon exam, determined he had no negative outcome as a result of his elopement on 12/25/20. Observations of each of the 4 exit doors with delayed egress were conducted with the FMD on 04/01/21 at 2:50 PM. When the FMD held the door handle down, the egress panel started beeping and after 15 seconds, the alarm sounded. On the C-Hall, once the exit door handle was pushed and the panel reached 12 seconds, an alarm sounded at the nurses' station along with a blue flashing light. After the alarms were tested on each exit door, the FMD reset the panel and made sure the doors were locked and secure. The facility provided the following Corrective Action Plan with the correction date of 12/28/20: 1. On the evening of 12/25/2020 Resident #4 eloped from facility at 7:23 PM and was subsequently observed by Nurse #2 who was in the parking lot, and at 8:10 PM saw the resident standing outside the door he had exited previously. Resident was outside the facility for 47 Minutes, as confirmed by the Administrator after reviewing video footage early on 12/26/20. When the nurse #2 came upon him, he was directly outside of the door he had exited, fully dressed, with shoes and socks and wearing two coats. Nurse #2 brought him back into facility. He was made comfortable by team members and was immediately assessed by the Nurse #1. The resident's vital signs were stable, and his assessment revealed no negative outcome. This was documented in the medical record that evening. The doctor on call was notified the same evening, 12/25/20. Further, as noted in the medical record, the resident was visualized at least hourly throughout the night to ensure there was no further elopement attempt or adverse impact from the elopement. The Medical Director / Attending Physician was notified and assessed the resident on 12/26 and noted in the medical record that the resident had no adverse effects from the elopement. His Elopement device was checked and noted to be operational on 12-24-20 and at the time of event on 12-25-20. The Director of Nursing (DON), Administrator, and Medical Director notified the family on 12/26/20 of the elopement and that no adverse impact had resulted from the elopement. 2. In order to protect other residents from the potential for elopement, at the DON's direction a head count of residents within the facility was performed that evening to ensure all residents were accounted for. Further, the specific egress door alarm and mechanical locking system that the resident walked through was identified by reviewing common area video and was inspected on the morning of 12/26/20. Facilities Maintenance staff and the Administrator assessed the exit door and discovered it was in a bypass mode, disabling the elopement alarm. This was corrected immediately and monitored frequently over the following two days to ensure it continued to properly function. This panel is unique from all other panels in the facility, and on 12/26/20, maintenance team members and the Asst. Facilities Director for Maintenance verified that all other exterior doors in the facility did not have the ability to bypass or override the alarm systems, which were designed, in part, to prevent elopement. Systems were in existence and utilized for team members to identify those residents at risk for elopement. All residents are consistently assessed for elopement risk upon admission to the facility, and these assessments are updated on quarterly basis, and upon any significant change of condition. Each resident assessed to be at risk for elopement had an elopement device in place. This device automatically engages the elopement prevention systems on exterior doors. In addition, the devices serve to identify any resident who is an elopement risk to team members. These devices are monitored daily to ensure they are operational, identifying the residents at risk for elopement and protecting these residents from elopement. In addition, residents at risk for elopement had further interventions in place including, monitoring for anxiety, monitoring exit-seeking behavior, offering reassurance as indicated, monitoring for wandering behaviors, provision of one-on-one diversional activities, and medication reviews. These interventions and the elopement devices are noted on each resident's individualized care plan and are made readily available to Nurses and CNAs to inform them in caring for their assigned residents. Further, nurses inform nursing assistants of the care needs, including elopement risk, of each resident at shift change and as changes occur. Further, the elopement devices serve as a visual cue to all team members indicating the resident's assessed to be at risk for wandering or exit seeking behaviors. 3. To prevent further elopements, team members were re-trained regarding elopement prevention and response protocols during 12/26/20 - 12/28/20, regarding the need to closely monitor residents wearing elopement devices, as they had been assessed as having an elopement risk. They were also re-in-serviced on elopement protocols regarding responding to door alarms, routine monitoring of residents, monitoring residents for increased agitation and exit seeking behaviors, and performing nightly checks on elopement devices. These nightly device checks continue to be provided to the DON to monitor checks are performed and to ensure the system continues to work as designed. Team members were instructed to immediately notify a supervisor or nurse when any resident had an acute episode of high anxiety and/or exit seeking behaviors for reassessment of their elopement risk. Each resident at risk for elopement is identified on the daily device testing log, and this same log is used by nurses for daily testing of the devices for proper operation. Staffing levels were good the evening the incident occurred and the entire Christmas Holiday weekend. We did not document the training thoroughly as is our usual practice. However, our leadership has attested to the fact that training was done and multiple team members have acknowledged the fact that training occurred at the time, and that training was helpful to their understanding. Further, ongoing compliance monitoring detailed below, and documented through QAPI, demonstrates that the re-in-service training provided to all staff not only occurred, but was effective. 4. To ensure sustained compliance, a Performance Improvement Plan (PIP) was developed on 12/26/20 noting the interventions that were put in place to address the root cause of the elopement on 12/25/20. A Root Cause Analysis was initiated on 12/26/20, analyzing the resident, staff, and mechanical systems involved. Root cause analysis indicates that Resident #4, was noted on MDS 10/08/20 to have Alzheimer's Disease with Behavioral disturbances and noted severe impairment in cognition for daily decision making and had no wandering episodes during the MDS assessment period. However, on 10/22/20 the resident was noted to be at risk for wandering and to have wandering behaviors with a Care Plan was initiated due to wandering, confusion, and exit seeking behavior. An elopement device was put in place at that time and checked nightly thereafter to ensure operationality. Other interventions included reorientation to person and family, redirecting as needed, distract resident while wandering by offering pleasant diversion, structured activities, food, conversation, television, and books. On the evening of 12/25/20 the resident was visualized to be in his room by nursing team members prior to his elopement and did not show any indication of exit seeking behavior. The resident was known to be sociable and enjoyed being outside on nice days. It appears the confused resident was simply intending to go for an evening stroll, as he dressed himself with two coats, but did not take any possessions with him. He chose to walk into the hallway to the outside door nearest his room, however, it is apparent from the video that the moment he stepped outside he changed his mind and attempted to reenter the building. The resident's behaviors previous to his elopement on 12/25/20 were consistent with his previous behaviors he demonstrated and that had been previously assessed by facility staff and were well known and communicated to facility staff. Root Cause analysis of team member actions on 12/25/20, noted that staffing was at acceptable levels, and team members interviewed by surveyors, noted that the resident was visualized by Nurse #1 at 6:40, and NA noted visualizing the resident on her first round after 6:00 pm. On interview by DON, both staff members noted the resident to be in his room, showing no agitation, active wandering or indication of exit seeking behaviors. NA #1 was providing pm care for her assigned residents at the time of the elopement, and Nurse #1 had begun her nighttime medication pass as was around the corner of the hallway, and out of sight of the door the resident exited. It is determined our analysis that the facility was properly staffed for the evening of the incident, and that the team members were appropriately performed visual round on each resident including Resident #4 throughout the night and were providing resident care to other residents at the time of the incident. Root Cause Analysis of the mechanical systems designed to prevent elopement indicates that the elopement was clearly a failure in the mechanical elopement prevention systems which allowed a properly assessed and supervised resident to open a door to the outside of the facility despite wearing a functional elopement prevention device. The analysis noted that the doors were inspected and noted to be functioning properly days earlier on the routine weekly audit, and that the resident's elopement device was noted to be functional when checked the night before, and upon return to the facility. The door the resident exited was an emergency exit, not regularly used by residents, visitors, or staff. When inspected the following morning by maintenance staff and the Administrator, the door was found to be in a bypass mode which disabled the secure locking mechanism as well as disabling the elopement prevention systems and alarms. This Bypass mode is easily identifiable and is indicated by dashes the LED panel. Further root cause analysis noted that this door was unique to all other doors in the facility, having a keypad panel that was a different brand and style from all others in the facility. Further, it was unique from other panels in that it had a bypass feature that could disable not only the locking mechanisms, but also the elopement prevention system alarms. It was further determined that there were two possible causes of the alarm panel being in by-pass mode. One of these possible causes was a ground fault, electrical short, or power surge that reset the panel into the by-pass mode. This could not be replicated on testing. The Other possible cause was a person with knowledge of the bypass code, manually entered the code placing the system into bypass. No one other than maintenance staff had knowledge of the bypass / override code. Further, as part of the root cause analysis the Administrator reviewed video from the previous week, noting no one who had exited during this time period. The Facility immediately addressed both of these possible causes. The door was reset to operational mode, and the door was extensively tested on [DATE]. Further, the Maintenance team member and the Administrator visualized the operational mode of the door panel multiple times throughout day 12/26 and 12/27/20. The Administrator also personally in-serviced the evening nurse who monitored it for proper operation throughout the night. On 12/28/20, maintenance team members installed a redundant door sensor alarm on this door, which alerts the Administrator and Maintenance director any time the door is opened for any reason. This system was tested extensively on 12/28/20 and weekly thereafter. Each time it is tested it has been noted to be functional and has no ability to be overridden at any time. This system is separate from and in addition to the elopement system. Every time this redundant alarm has been activated, it has been verified by the administrator that the elopement systems were operational as well. In addition, further upgrades to the system were contracted to further strengthen the system and are noted in the PIP initiated in 12/26/20. Ongoing monitoring of the resident's elopement prevention devices continues to be performed on a nightly basis, and all elopement systems on exterior doors continue to be tested weekly to ensure proper operation with results documented. The documents with monitoring results are reviewed regularly by maintenance and the Administrator to ensure compliance. These Weekly audits of proper door alarm operation and daily audits of elopement devices continue to be conducted and are provided to The Administrator who, in turn, reports the results of these monitoring activities to the QAPI committee on a monthly basis to ensure ongoing oversight occurs. The interventions put in place on 12/25/20-12/28/20 effectively addressed the root cause of the elopement, preventing further elopement. In addition, as part of the QAPI process at [NAME] Estates Health Center, the Performance Improvement Plan initiated on 12/26/20 has continued to be updated as new interventions were put in place to strengthen the elopement prevention systems and reported in the monthly QAPI meetings. The facility alleges compliance on 12/28/2020 The Corrective Action Plan was validated on 04/06/21 and concluded the facility implemented an acceptable corrective action plan on 12/28/20 once the alarm was reset on the C-Hall exit door and the door contactor was put in place to immediately send notifications to the Administrator and FMD when the exit door was opened. The Corrective Action Plan was reviewed during QAPI meetings held on 01/14/21 and 02/11/21. The weekly monitoring logs of the facility exit doors for January 2021 to March 2021 were reviewed with no concerns identified. Observations of the egress exit doors conducted with the FMD on 04/01/21 revealed the alarms on the doors were functioning properly and when the panel was reset, the doors were locked and secure. Review of the Secure Care Nightly Checklists for January 2020 to March 2020 revealed resident elopement devices were initialed as checked daily and functioning. The Administrator was unable to locate documentation of the staff training conducted on 12/26/20 to 12/28/20; however, multiple staff on various shifts were interviewed and verified they received re-education related to elopement in December 2020 and were able to describe facility processes for: what to do when a resident demonstrated elopement/exit seeking behaviors, monitoring of residents identified as high risk for elopement, responding to door alarms, and what to do in the event of an elopement.