Every finding on record at Golden Age Operations

Based on review of the facility's policy, record review, and interviews, the facility neglected to provide care and services for Resident (R)1, resulting in R1 successfully eloping from the facility, for 1 of 3 residents reviewed for neglect. On 06/06/25 at 12:30 PM the Administrator was notified that the failure to prevent a successful elopement from the facility constituted Immediate Jeopardy at F600. On 06/06/25 at 12:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/12/25. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect and Exploitation. On 06/06/25 at 3:42 PM, the facility provided an acceptable IJ Removal Plan. On 06/06/25, the survey team, validated the facility's corrective actions and determined that the facility put forth due diligence in addressing the noncompliance. This IJ is considered at Past Non-Compliance as of 05/13/25. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation with a revised date if 02/15/24, documented, the facility shall provide protection for the health, welfare and rights of each resident . Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . III Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring or residents with needs and behavior which might lead to conflict or neglect; . Review of R1's Face Sheet located in the resident's electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease, hyperlipidemia, hypertension, atherosclerotic heart disease and angina pectoris. Further review of the Face Sheet indicated R1's advance directives were Do Not Resuscitate (DNR). Review of R1's Medication Administration Record for the month of May 2025, revealed R1's Medical Conditions included but was not limited to: senile degeneration of brain, Alzheimers Disease, and insomnia. Review of R1's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating he was severely cognitively impaired. Review of R1's Elopement Risk Assessment, on admission, dated 05/05/25, revealed R1 is mobile with a device, R1 has one or more predisposing diseases, R1 is cognitively impaired (decreased safety awareness, disturbances in judgement, wandering). Further review of the assessment revealed no indications of elopement. Review of R1's Baseline Care Plan completed on 05/06/25, indicated no history of wandering/elopement. However, the Baseline Care Plan did indicate the following: Under the section Falls/Safety/Elopement indicated evaluate for unsteady gait, proper footware and maintain safe environment. Review of an undated video clip which was taken by a passerby and posted to social media revealed that R1 was outside by himself while it was raining. Further review of the video revealed R1 was in his wheelchair, which was in a grassy area, near the main road. During an interview with Housekeeper (HSK)1 on 06/05/25 at 10:48 AM, HSK1 stated, I was sitting on the porch on a 15 minute break, looking at my telephone, when I noticed [R1] in the ditch. I called for help, which was [Certified Nursing Assistant (CNA)1]. Attempted interview with CNA1 on 06/05/25 at 10:53 AM and 1:39 PM, was not successful. This surveyor received a call from CNA1 on 06/09/25 at 9:32 AM, CNA1 stated that she was coming down the hall when [HSK1] yelled, A resident is trying to get away. CNA1 stated that she went outside to help and R1 was heading over the hill towards the road. CNA1 further stated that she and HSK1 turned him around and he was brought back in. CNA1 concluded she didn't know how long he was out there, but he was alone when she got to him. During an interview with the Director of Nursing (DON) on 06/05/25 at 10:55 AM, she stated that she was notified that R1 was outside by the Business Office Manager (BOM) and when she looked outside, staff were bringing him back. The nurse did an assessment, and he was without injuries. During an interview with the Business Office Manager (BOM) on 06/05/25 at 11:05 AM, she stated, I received a call from a passerby stating that a resident was in front of the building, near the road, in a ditch. The BOM stated that she immediately alerted the staff. During an interview with the Administrator on 06/05/25 at 11:09 AM, the Administrator stated that the facility did not know that R1 was outside until the passerby called the facility. The Administrator stated that R1 was being discharged on the day of the elopement, and he was waiting on his family to pick him up. On 06/06/25 at 3:42 PM, the facility provided an acceptable IJ Removal Plan, which included the following: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 5/12/2025) - The resident directly involved in this alleged deficient practice was assessed with no injuries noted on 5/12/25. Additionally, the resident had a planned discharge in place to occur on 5/12/25. The resident was discharged on 5/12/25 as planned. - The DON and/or designee re-evaluated residents at risk for wandering/elopement utilizing a midnight census report checklist to indicate that residents had been re assessed and were accounted for. No new residents were identified as being at risk at for elopement. All residents were accounted for in the facility. - All doors with an outside exit were checked to ensure proper function. No issues were identified. - All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee. Any staff not in attendance received re education on their next scheduled workday. 2. Actions to Prevent Occurrence/Recurrence: Elopement and wandering residents' policy was reviewed. No revisions were necessary. - An elopement drill was conducted on 5/14/25 with no issues noted during the drill. - Newly admitted residents will continue to be assessed for elopement by the DON or designee and ensure that appropriate interventions are in place. - The DON or designee will ensure care plans are updated to ref ect any identified elopement risk. - A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until a pattern of compliance is maintained. Date Facility Asserts Likelihood of Serious Harm No Longer Exists: 05/13/25

Based on review of the facility's policy, record review, and interviews, the facility failed to provide adequate supervision for 1 out of 3 residents reviewed for accidents. On 06/06/25 at 12:30 PM, the Administrator was notified that the failure to prevent a successful elopement from the facility constituted Immediate Jeopardy at F689. On 06/06/25 at 12:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/12/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/25/25, the facility provided an acceptable IJ Removal Plan. On 06/25/25, the survey team, validated the facility's corrective actions and and determined that the facility put forth due diligence in addressing the noncompliance. This IJ is considered at Past Non-Compliance as of 05/13/25. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled, Elopement and Wandering Residents revealed, The facility shall ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents . Review of an undated video clip which was taken by a passerby and posted to social media revealed that R1 was outside by himself while it was raining. Further review of the video revealed R1 was in his wheelchair, which was in a grassy area, near the main road. Review of R1's Face Sheet located in the resident's electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease, hyperlipidemia, hypertension, atherosclerotic heart disease and angina pectoris. Further review of the Face Sheet indicated R1's advance directives were Do Not Resuscitate (DNR). Review of R1's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating he was severely cognitively impaired. Review of R1's Elopement Risk Assessment, on admission, dated 05/05/25, revealed R1 is mobile with a device, R1 has one or more predisposing diseases, R1 is cognitively impaired (decreased safety awareness, disturbances in judgement, wandering). Further review of the assessment revealed no indications of elopement. Review of R1's Baseline Care Plan completed on 05/06/25, indicated no history of wandering/elopement. However, the Baseline Care Plan did indicate the following: Under the section Falls/Safety/Elopement indicated evaluate for unsteady gait, proper footwear and maintain safe environment. During an interview with Housekeeper (HSK)1 on 06/05/25 at 10:48 AM, HSK1 stated, I was sitting on the porch on a 15 minute break, looking at my telephone, when I noticed [R1] in the ditch. I called for help, which was [Certified Nursing Assistant (CNA)1]. Attempted interview with CNA1 on 06/05/25 at 10:53 AM and 1:39 PM, was not successful. This surveyor received a call from CNA1 on 06/09/25 at 9:32 AM, CNA1 stated that she was coming down the hall when [HSK1] yelled, A resident is trying to get away. CNA1 stated that she went outside to help and R1 was heading over the hill towards the road. CNA1 further stated that she and HSK1 turned him around and he was brought back in. CNA1 concluded she didn't know how long he was out there, but he was alone when she got to him. During an interview with the Director of Nursing (DON) on 06/05/25 at 10:55 AM, she stated that she was notified that R1 was outside by the Business Office Manager (BOM) and when she looked outside, staff were bringing him back. The nurse did an assessment, and he was without injuries. During an interview with the Business Office Manager (BOM) on 06/05/25 at 11:05 AM, she stated, I received a call from a passerby stating that a resident was in front of the building, near the road, in a ditch. The BOM stated that she immediately alerted the staff. During an interview with the Administrator on 06/05/25 at 11:09 AM, the Administrator stated that the facility did not know that R1 was outside until the passerby called the facility. The Administrator stated that R1 was being discharged on the day of the elopement, and he was waiting on his family to pick him up. On 06/25/25, the facility provided an acceptable IJ Removal Plan, which included the following: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 5/12/2025) - The resident directly involved in this alleged deficient practice was assessed with no injuries noted on 5/12/25. Additionally, the resident had a planned discharge in place to occur on 5/12/25. The resident was discharged on 5/12/25 as planned. - The DON and/or designee re-evaluated residents at risk for wandering/elopement utilizing a midnight census report checklist to indicate that residents had been re assessed and were accounted for. No new residents were identified as being at risk at for elopement. All residents were accounted for in the facility. - All doors with an outside exit were checked to ensure proper function. No issues were identified. - All nursing staff on all shifts received education on wandering, elopement, supervision, and rounding to observe residents, and resident safety from the DON or designee. Any staff not in attendance received re-education on their next scheduled workday. Actions to Prevent Occurrence/Recurrence: Elopement and wandering residents' policy was reviewed. No revisions were necessary. - An elopement drill was conducted on 5/14/25 with no issues noted during the drill. - Elopement drills will occur monthly, at a minimum to ensure, residents are supervised and staff respond appropriately. - Newly admitted residents will continue to be assessed for elopement by the DON or designee and ensure that appropriate interventions are in place. - The DON or designee will ensure care plans are updated to reflect any identified elopement risk. - A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until a pattern of compliance is maintained. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 5/13/2025

Based on facility policy, observation, record review, and interview, the facility failed to develop a comprehensive care plan for of 2 of 3 residents. (Resident (R)22 and R24). Findings include; Record review of the facility policy dated 2025, titled Comprehensive Care Plan revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses including but not limited to acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment. Review of R22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/25, recorded R22 with a Brief Interview for Mental Status (BIMS) score of 9 out 15, indicating R22 had mild cognitive impairment. Review of R22's Physician Order dated 03/03/25, revealed oxygen 2 liters per minute (lpm) via nasal cannula (N/C) to be administered to keep oxygen saturation (oxygen in the blood) above 90% every shift. Review of R22's Care Plan revealed there was no Care Plan related to respiratory concerns, the use of oxygen, or obtaining oxygen saturation to keep above 90%. Further review of the Care Plan revealed a cardiovascular Care Plan, which did not reference the use of oxygen. During an interview on 03/19/25 at 9:43 AM, an interview with Registered Nurse (RN)2 and the Director of Nursing (DON). RN2 stated we remotely update the Care Plans. RN2 confirmed R22 did not have a Care Plan for the use oxygen. The DON confirmed that the Care Plans are updated by the corporate MDS remotely. Review of R24's Face Sheet revealed R24 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Dementia, emphysema, and abnormal gait. Review of R24's MDS with an ARD of 12/19/24, revealed R24 had a BIMS score of 3 out of 15, indicating R24 had severe cognitive impairment. Review of R24's Progress Notes dated 03/14/25 at 8:52 PM, revealed, Resident arrived to facility via stretcher with emergency medical personnel from hospital at 1320 . Resident left great toe was amputated. Resident surgical amputation site has sutures and is covered with dressing. Dressing dry and intact. There is no redness, draining, or any signs or symptoms of infection to site. Resident has special shoe that is to be worn, and dressing should be left in place until follow up appointment. Review of R24's Care Plan revealed there was no care plan addressing R24's surgical site. During an interview on 03/19/25 at 12:55 PM, with Licensed Practical Nurse (LPN)2, Unit Manager and the Director of Nursing (DON). They stated, the MDS Nurse was not here when she went to the hospital and had the amputation. They verified there was not a Care Plan in place. They further confirmed there should be a Care Plan for amputation in place but we don't have anyone doing them. 50850

Based on review of facility policy, observation, record review and interview, the facility failed to complete a dressing change using standards of practice to prevent cross contamination of a pressure ulcer, for 1 of 1 resident, (Resident (R)22), reviewed for pressure ulcers. Findings include: Review of the facility policy dated 2024, titled, Clean Dressing Change stated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and or cross/contamination. Setup clean field on the overbed table with needed supplies .Place a disposable cloth or linen saver on the overbed table. Place only the supplies to be used per wound on the clean field . Use no touch techniques to remove ointments and creams from their containers (i.e. use of tongue blade or applicator). Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment. Review of R22's Minimum Data sheet (MDS) with an Assessment Reference Date (ARD) of 01/04/25, revealed R22 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R22 had moderate cognitive impairment. Review of R22's Progress Note dated 03/07/25 at 11:10 PM, reveals a care conference note late entry, Resident reviewed with IDT for skin breakdown to her buttocks. Reported that resident had skin tears to the left and right buttocks. Order written for areas to be cleaned with normal saline and border gauze applied. Will continue to treat resident according to orders and wounds/skin will be assessed weekly until healed. Review of R22's Physician Order dated 03/07/25, revealed the following order: Balsam Peru Castor Oil External Ointment (Balsam Peru Castor Oil), Apply to bilateral buttocks topically every day and night. Discontinued on 03/21/2025. During an observation and interview of R22's wound treatment on 03/18/25 at 9:51 AM, with Registered Nurse (RN)2 revealed, upon entering the room, the privacy curtains were pulled and a Certified Nursing Assistant (CNA) was assisting with turning and repositioning, and had R22 turned and prepared for the treatment. RN2 entered the room, sanitized her hands and donned gloves. Sites were almost completely healed, pink. RN2 applied the [NAME] and [NAME] ointment from the tube to both areas, directly from the tube with gloved hands. RN2 held the tube of treatment in her gloved hand and placed the tube on the bed linens. After applying the ointment, she placed the tube in her pocket. She removed the gloves, then picked up a cup in one hand and held the dirty gloves in the other. She exited the room, went to the dining room, discarded the gloves in the trash and gave the cup to the kitchen. RN2 returned to the room, then washed her hands. She removed the cream from her pocket. She walked towards the treatment cart, but gave the Director of Nursing (DON) the tube of ointment and said it needed to be reordered. RN2 stated, the tube was on her night stand in the room. RN2 confirmed it was not sanitary to place it on the bed. When asked about why she didn't wash her hands after the treatment, RN2 stated she returned to the room and washed her hands, but didn't touch anything along the way because she had a cup in one hand and the gloves in the other. On 03/18/25 at 10:06 AM, an interview with Licensed Practical Nurse (LPN)1 revealed she had just placed R22's ointment back into the treatment cart. After discussing observations, she stated, the nurse should have had a barrier and placed the tube there or she could have poured it in a medication cup and left the tube on the cart. The tube was just given to me by my DON. I placed the tube back into the treatment cart. On 03/19/25 at 9:47 AM, an interview with the DON confirmed R22's ointment was given to her to reorder by RN2 and she handed it to LPN1. The DON stated, I expect the nurse to have a barrier for a dressing and items. Use a barrier for the cream or ointment. The nurse should sanitize or wash her hands before exiting the room.

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure 2 of 2 sampled residents (Resident (R)12 and (R)22), received the correct oxygen flow rate per physician's orders. Findings include: Review of the undated facility policy titled, Oxygen Administration revealed, Policy: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in cases of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Review of R12's Face Sheet revealed R12 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroximal atrial fibrillation, heart failure, long term (current) use of anticoagulants, acute ischemic heart disease, asthma, bipolar disorder, current episode mixed, mild, presence of automatic (implantable) cardiac defibrillator, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, gastro-esophageal reflux disease without esophagitis, ventricular tachycardia, pure hypercholesterolemia, and systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. Review of R12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R12 had mild cognitive impairment. Review of R12's Care Plan documented, Has oxygen r/t Dyspnea, Asthma. Documented goal indicated, Will have no s/sx of poor oxygen absorption through the review date. Documented intervention directed staff to, OXYGEN SETTINGS: O2 per provider orders. Review of R12's Medication Administration Record dated 03/01/25 - 03/18/25, revealed an order for oxygen at 2 liters with nasal cannula to keep 02 sats above 90%. Check 02 sats every shift. every shift related to ACUTE ISCHEMIC HEART DISEASE, DYSPNEA. Start Date 08/14/24. The document revealed documentation on the following days as noted with nurse initials: 03/17/25. Review of R12's Physician Order with a start date of 08/14/24, documented, O2 at 2 liters with nasal cannula to keep sats above 90%. Check O2 sats every shift. During an observation on 03/17/25 at 10:41 AM, R12 was lying in bed. R12's Oxygen via nasal cannula was set at 2.5 liters per oxygen concentrator. During an observation on 03/17/25 at 2:17 PM, R12 was receiving oxygen via nasal cannula at 2.5 liters per oxygen concentrator. During an interview on 03/17/25 at 2:22 PM, Registered Nurse (RN)1, verified the oxygen was set to 2.5 liters per minute and it should be on 2 liters per minute. RN1 adjusted to the oxygen to 2 liters per minute. During an interview on 03/19/25 at 9:50 AM, the Director of Nursing (DON) revealed, the nurses should have oxygen orders to get the resident's oxygen saturation. Some of the resident's oxygen rates are based on their saturation rates. The nurses should follow the doctor's orders based on the parameters. If the oxygen is on a different flow rate than the doctor's order specifies, this is a concern. Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses that included but not limited to: acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment. Review of R22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/25, revealed R22 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R22 had mild cognitive impairment. Review of R22's Physicians Orders dated 03/03/25, revealed oxygen 2 liters per minute (lpm) via nasal cannula (N/C) to be administered to keep oxygen saturation (oxygen in the blood) above 90% every shift. During an observation on 03/17/25 at 12:38 PM, revealed R22's oxygen concentrator was set to 1.5 lpm, connected to a nasal cannula. During an observation and interview of R22 on 03/17/25 at 2:18 PM, revealed the oxygen concentrator remained at 1.5 lpm. RN1 verified the oxygen was set at 1.5 lpm, and stated it should be at 2 lpm. RN1 concluded, Someone may have messed with it. I turned it up this morning. During an interview on 03/19/25 at 9:47 AM, the Director of Nursing (DON) stated, If a resident is on oxygen, they should have oxygen orders. We have set parameters, then follow the orders. It is a concern if the oxygen is not at the correct liter. 50850

Based on review of facility policy, observation, record review and interview, the facility failed to ensure proper handwashing and proper precautions utilizing gloves while removing and reapplying a transdermal patch for Resident (R)5, for 1 of 1 residents observed. Findings include: Review of the facility policy titled, Medication Administration, states, Policy: Policy Explanation and Compliance Guidelines: . 4. Wash hands prior to administering medication per facility protocol and product. 14. Remove medication from source, taking care not to touch medication with bare hand. 19. Wash hands using facility protocol and product. During an observation on 03/18/25 at 8:40 AM, during medication administration revealed, R5 was ordered Rivastigmine 4.6mg/24. Apply transdermal patch everyday. Registered Nurse (RN)1 prepared the medications for R5. RN1 signed the Medication Administration Record (MAR) to indicate the medications had been given. RN1 sanitized her hands, collected the medications and knocked on the door of the resident's room. RN1 placed the medications on the resident's bedside table. All of the by mouth medications were administered to the resident. RN1, with bare hands, removed the old transdermal patch and applied a new transdermal patch to R5's right arm without washing her hands. RN1 did not sanitize her hands or wear gloves before removing the old transdermal patch or before applying the new transdermal patch. During an interview on 03/19/25 at 9:50 AM, the Director of Nursing (DON) revealed that the nurses should wash their hands and wear gloves if needed for that specific medication. The DON stated that the nurses should sanitize their hands before and after medication administration. After utilizing the hand sanitizer three times, the nurse should wash their hands with soap and water. During an interview on 03/19/25 at 6:45 PM, RN1 confirmed that she had not sanitized her hands or worn gloves before removing the old transdermal patch and applying a new patch. RN1 stated, I do not wear gloves because I cannot reach the corner of the old patch to remove it with gloves on. I do not wear gloves to apply the new patch because it gets stuck on the gloves.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were timely administered for 1 (Resident (R)6) of 3 sampled residents observed for medication administration. Findings included: An undated facility policy titled, Medication Administration, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 06/10/2024 at 10:15 AM, the surveyor observed Registered Nurse (RN)1 administer R6 their 8:00 AM dose of oxybutynin chloride and sennosides-docusate sodium. R6's Order Summary Report, with active orders as of 06/10/2024, revealed an order dated 04/11/2024 for oxybutynin chloride oral tablet, give 5 milligrams (mg) by mouth four times a day for overactive bladder and sennosides-docusate sodium oral tablet 8.6-50 mg, give one tablet by mouth two times a day for constipation. R6's Medication Administration Record, for June 2024, revealed staff were to administer sennosides-docusate sodium oral tablet at 8:00 AM and 4:00 PM and the oxybutynin chloride oral tablet at 8:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. In an interview on 06/10/2024 at 11:07 AM, the Director of Nursing (DON) stated the MAR would list the exact time the medications are to be administered based on the frequency and the physician orders. The DON stated if medications were not administered within those time frames, they were late. In an interview on 06/10/2024 at 11:19 AM, RN1 stated she has worked at the facility for about three to four months and because she was still training, she was a bit slower with the administration of resident medication(s). RN1 stated she was not sure how many medications were administered outside of the parameters as most of the medications she administered on the B Hall were frequently late. In a follow-up interview on 06/10/2024 at 2:49 PM, the DON stated she was not aware of medications being late.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure two staff assisted with a mechanical lift transfer for 1 (Resident (R)4) of 3 sampled residents reviewed for accidents. The failure resulted in R4 sustaining a laceration to the back of their head. Findings included: An undated facility policy titled, Safe Resident Handling/Transfers, with a copyright date of 2023 revealed It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy specified, 10. Two staff members must be utilized when transferring residents with a mechanical lift. An Admission Record revealed the facility admitted R4 on 11/13/2023. According to the Admission Record, the resident had a medical history that included diagnoses of neurocognitive disorder with Lewy bodies, chronic embolism and thrombosis, insomnia, dyspnea, depression, protein calorie malnutrition, hallucinations, hemarthrosis, anemia, and hypotension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2024, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident was dependent on staff for chair/bed-to-chair transfers. R4's undated care plan, revealed the resident was at risk for falls related to impaired gait and/or balance, impaired awareness, increased weakness and/or fatigue. R4's Nursing Progress Note, dated 04/29/2024 at 3:31 PM, revealed the resident fell to the flow while attempting to be transferred from the bed to their wheelchair. The Nursing Progress Note revealed the resident hit their head on the floor during the fall and a pool of blood was found under the resident and the resident was noted to have a laceration to the back of their head. According to the Nursing Progress Note, the Director of Nursing (DON) was called the resident's room, the resident remained alert and oriented to person, place, time, and situation, and an ambulance was called to transport the resident to the hospital. The facility Summary Statement, signed by the Administrator and dated 05/02/2024, revealed the resident had a witnessed fall on 04/29/2024. Per the Summary Statement, new interventions included to remind the staff to encourage the resident to properly place the resident's hands on the mechanical lift and for there to be a two-person assist with the use of the mechanical lift. In an interview on 06/10/2024 at 1:13 PM, R4 stated when they cut their head, there was only one staff that transferred them. In an interview on 06/10/2024 at 1:20 PM, Certified Nurse Aide (CNA)4 stated R4 required two-person assistance for transfers with a mechanical lift. CNA4 acknowledged it was only her that transferred the resident with a mechanical lift when the resident fell on [DATE]. According to CNA4, she should have had assistance of another staff when she transferred to the resident. CNA4 explained that R4 held the bar of the mechanical lift instead of crossing their arms, and then the resident slid out of the mechanical lift onto the floor. Per CNA4, it was a busy morning, the other aides were busy, and she did not wait for assistance. CNA4 stated after the incident, the DON informed her that there had to be two staff to transfer a resident with a mechanical lift. In an interview on 06/10/2024 at 1:51 PM, the MDS Care Plan Coordinator stated two people were to be present when the mechanical lift was used. In an interview on 06/10/2024 at 2:55 PM, the DON stated R4 had a fall when they slid out of the mechanical lift. The DON stated she informed the staff that whenever the mechanical lift was used, two people must be present. In an interview on 06/10/2024 at 4:20 PM, the Administrator stated R4's fall on 04/29/2024 was reported to the state agency because the resident sustained a laceration. The Administrator confirmed there was only one staff that transferred the resident with a mechanical lift and there should have been two.

Based on interviews, record reviews and review of the facility's policy, the facility failed to assess the resident's risk and/or underlying causes, and the impact of the resident's condition upon admission into the facility for 1 of 1 resident (R )189. This failure had the potential to cause harm and neglect by failing to reveal possible preventable risks for repeated falls. Findings Include: Review of the undated policy titled, Fall Prevention Program, states, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of risk. 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. Review of the medical record revealed R189 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Subdural hemorrhage, type 2 diabetes mellitus, cerebrovascular disease, myocardial infarction, and chronic kidney disease. Review of R189's Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/07/23 revealed R189 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating that the resident was cognitively intact. R189 displayed no physical or verbal behavior and did not reject any care. The assessment also reveals that R189 has had 1 fall, without major injury, since admission. Review of R189's care plan dated 03/09/23 indicates that R189 is At risk for falls r/t history of fall (s). Impaired gait and/or balance, Impaired safety awareness. Interventions included are, Complete fall risk assessment per facility protocol, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter remove any potential causes if possible. Review of R189's medical records revealed that a fall post assessment was completed on 03/05/23 and 03/29/23. Review of R189's medical records revealed that the resident sustained a witnessed fall on 03/05/2023, and unwitnessed falls on 03/10/2023, 03/29/2023, and 04/02/2023. A post fall risk evaluation was completed on 03/05/2023 indicating a score of 14, and an evaluation on 03/29/2023 indicating a score of 16, revealing that R189 is a high risk for falls. After the fall on 04/02/23, the resident was then sent to the emergency room (ER) for further evaluation. Review of the local hospital's discharge note revealed R189 was admitted to the hospital 04/02/2023 at 09:41 AM presented to the Emergency Department (ED) after a fall. Per patient and husband patient has been hypoglycemic and gets dizzy. This time she tripped and fall hitting her head without an loss of consciousness (LOC). The CT head impression reveals subarachnoid hemorrhage in cortices of the right occipital. DC5 Subarachnoid hemorrhage. During an interview with R189's roommate on 04/18/23 at 11:47 AM, she stated that R189 had fallen about 13 times and about three of those times she had slid to the floor. She included that there were never any floor mats or anything on the floor. She added that there was not much supervision, and the resident didn't know how to balance herself well, she also explained that the fall that R189 had on 03/05/2023 in the cafeteria was the first fall she witnessed and that R189 had a black eye from that fall. During an interview with the Corporate MDS Consultant on 04/18/23 at 12:50 PM, she revealed that R189 was sent out to the ER for another medical related issue, due to hypoglycemia, but by the third fall that a resident sustains, the Interdisciplinary Team (IDT) meets and would put interventions in place. During an interview with the Director of Nursing (DON) on 04/18/23 at 1:09 PM, she revealed that after a resident sustains a second fall in the facility, they would then discuss it with the IDT team during their morning meetings. She also stated that a fall assessment is completed on every fall and documented in the resident's medical record. The DON stated that she was aware that R189 was admitted with cerebral hemorrhage and did not complete an initial fall assessment record, although she was aware that the resident was admitted with a history of falls. During an interview with the Administrator on 04/18/23 at 3:04 PM, she revealed that she expects for her nursing staff to see what is going on with the patient and tell the story through documentation and make sure that they are documenting and how they are assessed or what is done, she expects staff to follow policy. She also explained that in the IDT meeting, they look for tends or things to do differently.

Based on interviews, record reviews and review of the facility's policy, the facility failed to assess the resident's risk and/or underlying causes, and the impact of the resident's condition upon admission into the facility for 1 of 1 resident (R )189. This failure had the potential to cause harm and neglect by failing to reveal possible preventable risks for repeated falls. Findings Include: Review of the undated policy titled, Fall Prevention Program, states, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of risk. 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. Review of the medical record revealed R189 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Subdural hemorrhage, type 2 diabetes mellitus, cerebrovascular disease, myocardial infarction, and chronic kidney disease. Review of R189's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/07/23 revealed R189 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating that the resident was cognitively intact. R189 displayed no physical or verbal behavior and did not reject any care. The assessment also reveals that R189 has had 1 fall, without major injury, since admission. Review of R189's care plan dated 03/09/23 indicates that R189 is At risk for falls r/t history of fall (s). Impaired gait and/or balance, Impaired safety awareness. Interventions included are, Complete fall risk assessment per facility protocol, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter remove any potential causes if possible. Review of R189's medical records revealed that a fall post assessment was completed on 03/05/23 and 03/29/23. Review of R189's medical records revealed that the resident sustained a witnessed fall on 03/05/2023, and unwitnessed falls on 03/10/2023, 03/29/2023, and 04/02/2023. A post fall risk evaluation was completed on 03/05/2023 indicating a score of 14, and an evaluation on 03/29/2023 indicating a score of 16, revealing that R189 is a high risk for falls. After the fall on 04/02/23, the resident was then sent to the emergency room (ER) for further evaluation. Review of the local hospital's discharge note revealed R189 was admitted to the hospital 04/02/2023 at 09:41 AM presented to the Emergency Department (ED) after a fall. Per patient and husband patient has been hypoglycemic and gets dizzy. This time she tripped and fall hitting her head without an loss of consciousness (LOC). The CT head impression reveals subarachnoid hemorrhage in cortices of the right occipital. DC5 Subarachnoid hemorrhage. During an interview with R189's roommate on 04/18/23 at 11:47 AM, she stated that R189 had fallen about 13 times and about three of those times she had slid to the floor. She included that there were never any floor mats or anything on the floor. She added that there was not much supervision, and the resident didn't know how to balance herself well, she also explained that the fall that R189 had on 03/05/2023 in the cafeteria was the first fall she witnessed and that R189 had a black eye from that fall. During an interview with the Corporate MDS Consultant on 04/18/23 at 12:50 PM, she revealed that R189 was sent out to the ER for another medical related issue, due to hypoglycemia, but by the third fall that a resident sustains, the Interdisciplinary Team (IDT) meets and would put interventions in place. During an interview with the Director of Nursing (DON) on 04/18/23 at 1:09 PM, she revealed that after a resident sustains a second fall in the facility, they would then discuss it with the IDT team during their morning meetings. She also stated that a fall assessment is completed on every fall and documented in the resident's medical record. The DON stated that she was aware that R189 was admitted with cerebral hemorrhage and did not complete an initial fall assessment record, although she was aware that the resident was admitted with a history of falls. During an interview with the Administrator on 04/18/23 at 3:04 PM, she revealed that she expects for her nursing staff to see what is going on with the patient and tell the story through documentation and make sure that they are documenting and how they are assessed or what is done, she expects staff to follow policy. She also explained that in the IDT meeting, they look for tends or things to do differently.

Based on record review, facility policy review, and interviews, the facility failed to ensure the comprehensive care plan was developed with the participation of the resident and the resident representative for two (Resident (R) 2 and R6) of 33 residents sampled. Findings include: Review of the facility's undated policy titled, Care Planning-Resident Participation revealed, Policy: This facility supports the resident's right to be informed of and participate in his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. 2. The facility will notify the resident and/resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. 3. The facility will encourage and assist the resident and or assist the resident representative to participate in choosing care and treatment options including: a. Initial decisions about treatment b. Decisions about changes c. The right to refuse treatment. 4. The facility will discuss the plan of care with the resident and or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. 1. Review of the Admission Record in the electronic health record (EHR) revealed the facility admitted R2 on 10/21/22 with diagnoses that included major depressive disorder, anxiety disorder, and dependence on supplemental oxygen. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/23, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. During an initial interview with R2 in his room on 04/17/23 at 2:01 PM, the resident was asked if he attended his scheduled care plan meetings. R2 stated, I do not know what a care plan meeting is. The facility could not provide a sign-in sheet of attendance from the care plan meeting for R2. During an interview with the MDS Consultant in the administration office on 04/18/23 at 12:27 PM, the MDS Consultant stated the facility was just made aware of the issue and had made a list of residents who had missed their care plan meetings. When asked, the MDS Consultant stated R2 did not have a 48-hour care plan meeting, and the resident nor his family were informed about a care plan meeting. During an interview with the Social Services Director (SSD)/Admission Coordinator in the administration office on 04/20/23 at 9:02 AM, the SSD stated the MDS Coordinator mailed out a letter to the family representative or if the resident was their own responsible person, she verbally told them when they were having a care plan meeting. The SSD stated the family would call the facility back and whoever answered the phone would take a message and then let the MDS Coordinator know if the family or the resident could attend or not. She stated if they could not come, then the facility would have the meeting and the resident representative could participate by phone. The SSD also stated the Certified Nursing Assistant (CNA) brought the resident to the care plan meeting, and the resident's CNA was also involved in the care plan meeting. When asked if R2 had a care plan meeting, she stated not to her knowledge. During an interview with the Director of Nursing (DON) in front of her office on 04/20/23 at 10:00 AM, the DON stated, Residents should be invited to the care plan meeting to discuss what they like and dislike. During an interview with the Administrator on 04/20/23 at 10:14 AM, she stated, The facility is in fact having care plan meetings, but I don't always attend the meetings myself. When asked if she knew of R2 having a care plan meeting, she stated, I do not remember. 47257 Review of the medical record revealed the facility admitted R6 on 11/17/22, with diagnoses including, but not limited to, multiple sclerosis, gastrointestinal hemorrhage, muscle wasting and atrophy, chronic obstructive pulmonary disease, anxiety disorder and depression. Review of R6's Quarterly MDS Assessment with an ARD of 02/24/23 revealed R6 had a BIMS score of 15 of 15, indicating that the resident is cognitively intact. The resident does not exhibit any verbal or physical behaviors to include rejection of care. R6 has functional limitation in range of motion, of which he requires limited assistance with personal hygiene, toilet use, transfers, and bed mobility, requiring the physical assistance of one person. Review of R6's care plan revealed interventions included for various focus areas include, Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. It also reveals an intervention of Inform the resident/family/caregivers of any new area of skin breakdown. An interview with R6 on 04/17/23 at 12:52 PM revealed that the facility had not asked if he or his family members would like to attend a care plan meeting that provided him with the extent of current and future care that he is receiving. R6 also included that the facility does not share with him the information that is provided after a care plan meeting has taken place. An interview with the MDS consultant on 04/18/23 at 12:27 PM revealed that the facility has been without a full time MDS coordinator since October of 2022. The MDS consultant also explains that, Since we were made aware of the issue, we have made a list of residents that have missed their care plan meetings. They are also actively trying to hire for a fulltime MDS person. An interview with the facility Administrator on 04/20/23 at 8:54 AM revealed that the Inter-Disciplinary Team (IDT) comes together to discuss the care plan for the residents, and they will provide an invite to the residents and resident representatives either by going to tell the resident or sending a letter out to their families. The Administrator added that this is their current process, and they are currently following this practice, and this has been in effect since she has been here. The resident representatives call the facility and confirm their attendance intentions. The Administrator also states the MDS coordinator and Social Worker have the shared task of sending out the invites to the resident and their representatives. If the resident chooses not to attend their care plan meeting, then the Social Worker or MDS coordinator provides the details of the meeting with them and provides an opportunity for them to explain to them and/or their families. The Administrator informed the surveyor at 9:55 AM on 04/20/23, that she was not able to provide any information or documentation for R6's care plan meeting or where he or his family had been provided an invite to attend any care plan meetings.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standard of quality for one (Resident (R) 14) of three residents observed during observations of medication administration. Observations revealed R14's blood sugar was not checked as ordered. Findings include: On 04/18/23 at 8:00 AM, during a medication administration observation in R14's room, Licensed Practical Nurse (LPN)1 did not obtain the resident's fingerstick blood sugar (FSBS) level. A review of R14's care plan indicated the resident was at risk for unstable blood glucose related to stress, sedentary activity level, and lack of adherence to diabetes management due to the resident having diabetes and being insulin dependent. R14's goals indicated the resident would not have any complications related to diabetes through the review date. Interventions included for staff to administer the resident's diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness. On 04/20/23 at 9:04 AM, a review of the electronic health record (EHR) for R14 revealed a verbal order written by a LPN to check blood sugars before meals, dated 10/19/22 at 7:00 AM. A review of a Blood Sugar Graph with documentation of blood sugars for R14 from 03/01/23 to 04/20/23 revealed no evidence the resident's blood sugar was checked from 03/10/23 to 04/17/23. A review of the Medication Administration Record (MAR) for April 2023 revealed no evidence R14's blood sugar was checked during the month of April until 04/18/23 at 3:00 PM. On 04/18/23 at 10:30 AM, during an interview, LPN1 stated blood sugar should be checked if there was an order for a FSBS or if the resident showed signs and symptoms of hypoglycemia, and the FSBS would be documented on the MAR and under vital signs. LPN1 was asked to go to the resident's chart to see the last FSBS, and she stated, The last FSBS was documented on 03/09/23 at 2:26 PM. On 04/18/23 at 10:45 AM, during an interview with the Director of Nursing (DON), she stated that she expected nurses who were administering insulin to check the FSBS level, even if there was no order for the FSBS. She also stated the nurse should notify the provider regarding the lack of an order for FSBS. On 04/18/23 at 11:00 AM, during an interview with the Medical Doctor (MD), he stated he expected nurses to check FSBS levels prior to administering insulin. The MD further stated staff would not call him regarding the resident refusing a FSBS, they would call the Nurse Practitioner (NP). On 04/18/23 at 1:41 PM, during an interview with the Administrator, she stated, I would defer to the DON regarding insulin administration and FSBS.

Based on interview and record review, the facility failed to make good faith attempts to improve performance through its Quality Assurance Committee. The facility failed to provide consistent care plan meetings for its residents and resident representatives dating back to November of 2022. Findings include: Review of an undated facility policy titled, Quality Assurance Performance Improvement, revealed its purpose is to enable the facility to take a proactive approach to continually improve the way care is provided to residents. QAPI is integrated into all care and services with a focus on clinical care, quality of life, resident choice, balance between safety and choice, and evidence based best practices. In an interview with the Minimum Data Set (MDS) consultant on 04/18/2023 at approximately 12:27 PM revealed the facility has been without a full-time MDS coordinator since October of 2022. There is a list of residents that have missed their care plan meetings, and the facility is actively trying to hire a full-time MDS coordinator. The consultant stated a performance improvement plan (PIP) was in place. In an interview with the Administrator on 04/20/2023 at approximately 11:30 AM revealed the facility only started a PIP to address the issues with resident / representative participation in care plan meetings that day. The facility lost its MDS Coordinator in December of 2022. At the time, the Administrator had discussed with Social Services and MDS that care plan meetings and care plan participation needed to be addressed. The Administrator believed the issue had been fixed at that time but became aware that the issue had not yet been resolved during the survey. Since the facility does not collect data on care plan meetings and care plan meeting participation, the only way the QA Committee could have known the care plan issue was ongoing was if Social Services or MDS had brought it to their attention. The last QA committee meeting was in March, which MDS did not attend. The issue of care plan meetings was not raised at that time. By the Administrator's estimate, the last time they had been able to provide consistent care plan meetings with participation from residents and resident representatives was in November of 2022 - prior to the departure of the last MDS coordinator.

Based on observation, facility policy review, and interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable disease for two (Resident (R) 14 and R6) of three residents observed during medication administration. Observations during medication administration revealed the nurse did not perform hand hygiene between residents after contact with the residents during medication administration. Findings include: Review of the facility's undated policy titled, Medication Administration, revealed, 16. Wash hands using facility protocol and product. Review of the facility's undated policy titled, Hand Hygiene, revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanations and Compliance Guidelines: 2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Review of the undated Hand Hygiene Table revealed, Use either soap and water or Alcohol Based Hand Rub (ABHR is preferred) before performing resident care procedures, between resident contacts, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, and before preparing or handling medications. Observations of medication administration on 04/18/23 from 8:00 AM until 8:18 AM on the unit revealed at 8:00 AM, Licensed Practical Nurse (LPN)1 sanitized her hands after preparing medications for R14 and before entering the resident's room. The LPN then administered the medications to R14. LPN1 then left the room without washing or sanitizing her hands and began to prepare medications for the next resident. At 8:10 AM, LPN1 administered a nasal spray to R6. The LPN used a tissue to wipe the top of the nasal spray and did not wear gloves or sanitize her hands after administering the medication or after exiting the resident's room. On 04/20/23 at 9:40 AM, during an interview with LPN1, she stated, I thought I sanitized my hands after coming out of [R14's] room. LPN1 also stated, I had no reason why I did not sanitize my hands. On 04/20/23 at 10:02 AM, during an interview with the Director of Nursing (DON), she stated, I expect nurses to perform hand hygiene before and after medication administration and before and after using gloves. She also stated, I do not expect nurses to wear gloves to administer nasal spray but if it is the nurse's preference to wear gloves, they need to perform hand hygiene before and after use.

Based on record review and interview, the facility failed to ensure the delegated resident representative had the authority as determined by the court to exercise the resident's rights for decision making by not obtaining documentation of a court appointed representative for a resident who is not able to make their own decisions for one (1) (Resident #12) of one (1) resident reviewed. The sample size was 16. The findings included: Review of records for Resident #12 revealed an admitted [DATE] from an acute care hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was admitted to Hospice on 5/19/21. Review of the History and Physical (H&P) dated 5/28/21, for Resident #12 revealed prior to hospitalization , Resident #12 lived in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). The H&P noted Resident #12 has no family. Review of the face sheet for Resident #12, noted a responsible party/emergency contact for Resident #12. Review of documents in the record of Resident #12 included but not limited to, Consent to Treat, Authorization to Release Healthcare Information, and Medicaid Hospice Election Form revealed the individual listed as the responsible party on Resident #12's Face Sheet was the person who signed the paperwork to admit Resident #12 to the facility on [DATE] and to Hospice on 5/19/21. Review of the record for Resident #12 revealed there is no legal documentation given the designated responsible party the authority to exercise the resident's rights or to make medical and financial decisions for Resident #12. There is no Power of Attorney (POA) document or Guardianship in the record for Resident #12. Interview with the Administrator at 3:15 p.m. on 7/28/21 revealed the facility does not have paperwork for a POA or Guardian for Resident #12. He/she stated in South Carolina, sometimes in homes for the disabled such as group homes or assisted living, when the resident has no family, the facility will take the responsibility for making medical decisions for that person. The Administrator stated he/she would contact the person listed as the responsible party/emergency contact #1 and see if he/she has legal papers giving him/her the right to make medical decisions for Resident #12. The Administrator stated if he/she could not provide those documents, then the facility would have to pursue and apply to the court for a legal guardian for Resident #12. On 7/29/21 at 9:30 a.m. in a follow up interview with the Administrator, he/she provided for review an email from the person listed as the responsible party for Resident #12 which stated he/she did not have legal guardianship or POA for Resident #12 as it was not required when Resident #12 resided in the ICF/IID. The Administrator stated he/she was not aware Resident #12 did not have a legal guardian. He/she stated he/she would contact the corporate office for the facility to check on the process to apply for a legal guardian for Resident #12. On 7/30/21 at 10:15 a.m., the Administrator stated the corporate office had contacted legal counsel to see what needed to be done to apply for a court appointed guardian for Resident #12. He/she confirmed the facility had not started the legal process of obtaining legal guardianship for Resident #12 but felt it would be done soon as they were now aware Resident #12 did not have a legal representative.

Based on observation, interview, record review and facility policy review, the facility failed to implement protocols for use of Personal Protective Equipment (PPE) and handwashing for Standard, Contact and Droplet Precautions in residents' rooms and in the residents' dining room. In addition, the facility failed to perform adequate sanitary environmental cleaning in the residents' rooms and in the dining room during meals. These failures affected all 33 residents residing in the facility, creating the potential for transmission of coronavirus (COVID)-19. Findings include: The policy titled, Infection Control Overview & Policy, undated, indicated: The purpose of this Infection Control Program .is to: (1) Investigate, control, and prevent infections in the facility; (2) Communicate the environmental and/or dining services procedures that should be applied in the field; .(4) To comply with centers for Medicare and Medicaid Services (CMS) guidelines in relation to CMS F880 tag found in CFR 483.80(a)(1)(2)(i)-(iii)(v)-(vi)(e). In addition to this program, it is important that all infection prevention and control practices reflect current Centers for Disease Control (CDC) guidelines .Preventing Spread of Infection .Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; Implement hand hygiene (hand washing) practices consistent with accepted standards of practice .(1) (Use) proper .personal protective equipment when. delivering food to a resident in isolation .Infections and diseases are transmitted in several ways including: A. Airborne .B. Contact with an infected object, person or surface (touching); C. Droplet (when someone coughs, sneezes, or talks) .B .Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room .Environmental Services Employees .1. Use effective quaternary germicidal solution along with systemic cleaning of all resident rooms. The facility provided the policy titled, Interim Recommendations for Terminal COVID-19 Isolation Room/Unit Cleaning, dated 5/20/2020 which directed: .steps involved in cleaning a COVID-19 isolation room . include: 7. Knowing the timing and method of cleaning reusable materials .It is highly important that we use an EPA (Environmental Protection Agency) approved solution for .cleaning isolation rooms to ensure the product in use is effective against the specific germ .C. (use) an EPA approved solution according to manufacturer specifications .(EPA List N). Be sure to follow the manufacturer's recommended dwell time .contact time . 1. According to epa.gov, The EPA expects all products on List N to kill the coronavirus [DIAGNOSES REDACTED] (Severe Acute Respiratory Syndrome)-CoV-2 (COVID-19) when used according to the label directions. According to List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (COVID-19) all products on this list meet the EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19. The product Virex Tb, Ready-To-Use revealed a contact time (on the surface) for two (2) minutes was required. During interview on 9/23/2020 at 1:48 p.m., Housekeeping staff (HK) #1 stated s/he used Virex for daily cleaning and for deep cleaning the rooms. S/he stated s/he sprayed it on and then wiped it dry. S/he stated, You don't really have to leave it on at all; you can just wipe it off right away. HK #1 exhibited the Virex Tb, Ready-To-Use product used by HK staff; the label directed, Contact time (leave product wet) for two (2) minutes. During interview on 9/24/2020 at 11:57 a.m., the Maintenance Supervisor (MS) stated s/he was filling in for the Housekeeping Supervisor. The MS stated s/he provided instruction for the staff for PPE use and completed the N-95 mask fit testing for all staff in the event of a Covid case. The MS stated for the daily cleaning of Transmission-Based Precautions (TBP) rooms, the Housekeeping staff should wear appropriate PPE including a mask, gloves, face shields/goggles, gown and foot coverings; the foot coverings were available in the front office, and face shields were available in the HK carts. The MS stated s/he was not familiar with the directions on the Virex bottle label stating, I would expect; you would think they (HK staff) would know (the label directions). The whole purpose of the stuff (Virex) is that it kills everything. 2. During interview on 9/23/2020 at approximately 10:00 a.m., the Administrator stated the facility did not have any Covid positive cases but had four (4) residents in 14-day quarantine because they were new admissions or had been out of the building on appointments. The four (4) rooms listed by the Administrator for transmission based precautions (TBP): Rooms 102, 106, 108 and 110. Observation revealed four (4) rooms with two (2) TBP signs on the doors: Room #s 102, 106, 108 and 110. The sign posted on the doors for Contact Precautions directed, STOP. Everyone Must: Clean their hands, including before entering and when leaving the room .Put on gloves before room entry . Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . The sign for Droplet Precautions directed, STOP. Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry (picture of a face shield or goggles); Remove face protection before room exit. During interview on 9/23/2020 at 1:55 p.m., Licensed Practical Nurse (LPN) #1 stated the facility had no positive Covid cases; however, four (4) residents were in quarantine at this time because they were new admissions or had been outside the facility to appointments. LPN #1 stated the four (4) quarantine rooms had signs so staff knew what type of TBP were in place, and which PPE staff should wear in the room. LPN #1 stated the quarantine rooms had signs for both Contact Precautions and Droplet Precautions, and staff should wear a gown, gloves, a mask and eye protection - goggles or a face shield. LPN #1 stated s/he wore glasses, so did not need extra eye protection. During interview on 9/24/2020 at 11:40 a.m. LPN #2 stated the night shift cleaned the medication cart because the cleaning products were kept in the medication room which was near where they kept the carts at night. LPN #2 further stated residents were kept in quarantine precautions after they went out for an appointment or were new admissions. At approximately 11:43 a.m., LPN #2 entered Resident #5's room (room [ROOM NUMBER]) which was posted with two (2) bright green signs for Contact Precautions and Droplet Precautions only wearing a surgical mask. Observation from the doorway revealed the LPN wearing only a surgical mask inside the room. LPN #2 did not wear a clean mask, gloves or a gown and assisted the resident to button his/her pants. After exiting the room, LPN #2 stated s/he wore gloves to assist the resident and washed his/her hands afterwards. This was not observed. LPN #2 stated s/he knew if a resident was on TBP because there would be a PPE cart near the door or hanging on the door. LPN #2 stated, Housekeeping must have moved the cart; it's not here. LPN #2 further stated, I'm not sure of the difference between quarantine and isolation and precautions. LPN #2 stated s/he judged the isolation precautions based on the cart containing PPE and did not notice the sign on the door. LPN #2 stated, I'm sorry about not removing the mask (before leaving the room); I'll remove it now. When asked about the Contact and Droplet Precautions signs, LPN #2 stated, I helped (the resident) buckle (his/her) pants; I did wear gloves, and I washed my hands before I left the room. I have a mask on, and I did not see the sign about the gown, and I did not remove my mask before leaving the room. It's a good question about the eye protection; I have not seen it here; I have never seen the eye protectors here. During a follow-up interview on 9/24/2020 at 1:24 p.m., LPN #2 stated s/he learned that the eye protection was used only for a resident who tested positive for Covid. LPN #2 stated s/he thought quarantine meant the resident should stay in their room and staff should wear a mask, but the resident wasn't on droplet precautions since they weren't Covid positive residents , despite the Droplet Precaution sign on the door. 3. Observation on 9/24/2020 from 12:36 p.m. to 1:23 p.m. in the residents' dining room revealed eight (8) residents eating at separate tables with one (1) resident per table. The tables and residents were spaced at least six (6) feet apart. When a resident finished the meal, another resident took their turn after the table was cleaned and sat at the table. Observations included: - 12: 36 p.m.: A resident touched his/her straw and picked up his/her fork, then set down the fork. Certified Nursing Assistant (CNA) #1 picked up the fork with bare hands, cut the resident's spaghetti, and set the fork on the resident's plate. CNA #1 did not clean his/her hands before or after touching the resident's fork; the CNA then donned gloves without first washing his/her hands. - 12:37 p.m. CNA #2 picked up a resident's used cup and packaging following the meal, placed the items in the trash and dirty dish area, did not wash hands, and then donned gloves. At 12:40 p.m. wearing the same gloves, CNA #2 cleaned a resident's table, touched his/her own hair and cleaned another resident's table. -12:42 p.m. CNA #2's mask fell below his/her nose. CNA #2 continued to pull a table into position, went to a plastic storage box and pulled open a drawer, removed a used resident's cup and placed it in the dirty dish area, and pushed a resident's wheelchair out to the hall. -At 12:43 p.m., CNA #2 pulled his/her mask up over his/her nose, then returned and cleaned a table, continuously wearing the same gloves with unwashed hands. CNA #2 delivered a tray of food to a resident, then removed his/her gloves and sanitized his/her hands. CNA #2 did not don new gloves and cleared used dishes and moved a resident in a wheelchair to the door. Then CNA #2 pulled up his/her own mask to cover the nose on the outside of the mask. - 12:45 p.m., two (2) residents entered to eat and staff did not offer to clean their hands before the meal. - 12:52 p.m. CNA #2 cleaned his/her hands, cleared used resident dishes, did not wash hands, donned new gloves, touched and pulled up his/her mask, then sanitized a table. - 12:54 p.m., CNA #2's mask fell under the nose; he/she moved it into place at 12:55 p.m. touching the outside of the mask and did not clean his/her hands. - 1:00 p.m., CNA #2 pulled the outside of the mask up over his/her nose and did not clean hands while s/he sat across the table with a resident who was eating. -At 1:06 p.m. CNA #2 picked up and handed a napkin to a resident without cleaning his/her hands first. - 1:08 p.m. CNA #2 pulled the outside of the mask up over his/her nose. During a conversation with another staff, the mask slipped down below the nose again as s/he continued to sit at the table with a resident eating. -At 1:10 p.m., CNA #2 brought two (2) napkins out of a plastic storage drawer, handed them to a resident, but the CNA had not cleaned his/her hands first. CNA #2 then pulled up the outside of the mask again over his/her nose. -At 1:12 p.m., CNA #2's mask slipped under the nose again and s/he pulled it up on the outside of the mask; then got a spoon out of the drawer, gave it to the resident, and pulled up the mask again. -At 1:13 p.m., the resident picked up and used the spoon given to her/him by CNA #2. -1:14 p.m., CNA #2 pulled up the mask again. -At 1:15 p.m., CNA #2 donned gloves without first washing his/her hands, cleared dishes, and rubbed his/her right shoulder. -At 1:16 p.m., CNA #2 removed gloves and sanitized his/her hands. CNA #2 had not cleaned his/her hands since 12:53 p.m. - 1:17 p.m., CNA #2 pulled the mask over the nose without cleaning his/her hands while sitting again at a resident's table. - 1:19 p.m., CNA #2 pulled the mask over the nose without cleaning his/her hands while sitting again at a resident's table. - 1:20 p.m., CNA #2 pulled down his/her mask with bare hands and scratched the side of his/her right eye, then pulled up the mask again without cleaning his/her hands. - 1:21 p.m., CNA #2 poured tea into a Styrofoam cup, pushed the lid down and unwrapped a straw, put it in the cup and handed it to a resident. CNA #2 had not cleaned his/her hands since 1:16 p.m. - 1:22 p.m., CNA #2 pulled the mask over the nose without cleaning his/her hands again. During interview on 9/24/2020 at 1:42 p.m., CNA #2 stated they sanitized the tables in the dining room after each resident finished and left the tables wet for 10 minutes. CNA #2 stated staff should always offer to clean the resident's hands before a meal, and staff should always wear a mask covering the nose and mouth. CNA #2 further stated s/he should have sanitized his/her hands between each task in the dining room and should not have touched herself or the outside of the mask without cleaning hands and donning gloves. CNA #2 stated, I have trouble keeping the mask up and not slipping down, and I know I had to adjust it again right now (during the interview). During interview on 9/24/2020 at 2:58 p.m., CNA #1 stated staff was supposed to wash hands before and after touching items the residents touched. CNA #1 agreed s/he did cut up a resident's spaghetti, but denied she failed to wash hands before and after touching the resident's fork. Handwashing was not observed before or after CNA #1 touched the resident's fork. 4. Observation on 9/24/2020 at 5:41 p.m. revealed CNA #1 entered room [ROOM NUMBER] with two (2) plastic grocery bags wearing only a mask and handed the bags to the resident. At 5:42 p.m., CNA #1 stated she did not wear the proper PPE because the resident had Contact and Droplet Precautions signs on the door, and stated, I wiped off the bags, and only handed them to (the resident). Observation on 9/24/2020 from 5:42 to 5:45 p.m. revealed CNA #3 delivered room trays to Rooms 106, 108 and 110 which were rooms with signs for Contact and Droplet precautions. CNA #3 had on a mask and gown, no gloves and did not change the PPE or clean his/her hands between rooms. During interview at 5:50 p.m., CNA #3 stated, I was supposed to put PPE on and change between each room, but I did have my hands kind of full. CNA #3 stated s/he did have PPE and TBP education and should have followed the same PPE guidelines for quarantine as for the precautions. CNA #3 further stated, We should only change our gown and gloves between rooms I think; I'm sorry, they didn't tell us if we should change our masks or wear gloves to pass trays. During interview on 9/24/2020 at 6:03 p.m., LPN #3 stated for quarantine residents, they were on Contact and Droplet Precautions and the PPE worn should include a mask, gown and gloves; staff should always leave the PPE in the room and put on new PPE between rooms. S/he stated if staff was delivering trays and not touching anything in the room, they should clean their hands and change their gloves between resident rooms. During interview on 9/25/2020 at 12:47 p.m., the Director of Nursing (DON) stated LPN #2 should have worn a mask, gown and gloves when going into the room, and changed out of them before leaving the room, especially after hands-on care. The DON stated the staff were educated to wear eye protection only for care involving splashing, or a positive Covid case. The DON further stated that s/he had to re-educate staff about the differences between isolation and quarantine, because they were the same thing. The DON agreed staff was still confused about the differences, and when to wear which PPE. The DON agreed staff should never adjust the mask by the front of the mask and should use handwashing and gloves when serving in the dining room between tasks. S/he stated staff should wear a mask, gown and gloves between rooms when serving meals in quarantine rooms, and wash hands and change gloves between rooms if the only thing touched was the resident's tray. During interview on 9/25/2020 at 4:20 p.m., the Administrator stated nursing staff should follow the education they had been given for PPE use according to the facility's policies and the CDC Guidelines, which their policies followed.

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision to a resident with exit seeking behaviors, failed to ensure all exit doors were secured, and failed to complete an elopement risk assessment on admission for one of three sampled residents (Resident #1) reviewed for exit seeking behaviors. On 04/25/2020 at 8:15 PM, Resident #1 eloped from the facility and was found at a nearby residence approximately one hour later. The facility Administrator was informed on 04/30/2020 at approximately 7:38 PM that Immediate Jeopardy existed on 04/25/2020. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/01/2020 at approximately 4:30 PM and the Immediate Jeopardy at F689 was removed with an effective completion date of 5/01/2020 and lowered to the scope and severity of D. Findings include: The facility admitted Resident #1 on 03/06/2020 with [DIAGNOSES REDACTED]. Review of the admission Wandering Risk Scale dated 03/06/2020, located in the electronic medical record (EMR) indicated Resident #1 was a wandering risk. The baseline care plan dated 03/09/2020 revealed Resident #1 was an elopement risk. Interventions included the use of a wander guard device (a device used to alert staff when a resident attempts to exit the building) and use of verbal redirection from staff. Review of the EMR did not reveal documentation that an assessment to assess Resident #1's risk of elopement was completed. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/13/2020, indicated Resident #1 had a Brief Interview of Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment, was independent for ambulation, and used a wander guard device on a daily basis. Review of the care plan dated 03/21/2020 revealed Resident #1 was an elopement risk due to advanced dementia and the ability to ambulate with interventions that included use of a wander guard device and to monitor the resident's whereabouts frequently. Review of the behavioral tracking data located in the EMR, revealed Resident #1 exhibited wandering behaviors on 03/10/2020, 03/13/2020, 03/14/2020, 03/15/2020, 03/20/2020, 03/24/2020, 03/25/2020, 03/28/2020, 03/30/2020, 03/31/2020, 04/01/2020, 04/06/2020, 04/08/2020, 04/19/2020, and 04/22/2020. The EMR did not include documentation to identify how Resident #1's elopement risk/whereabouts was being monitored. Review of the facility incident report dated 04/25/2020 at 8:15 PM, revealed Resident #1 entered the kitchen area of the facility through an unsecured door and eloped from the facility through an unsecured exterior door that was not equipped with an alarm or wander guard system alarm. Resident #1 was found at a nearby residence and returned to the facility at approximately 9:15 PM, one hour later. Review of the nurse's note dated 04/25/2020, located in the EMR, revealed that at 8:15 PM, The resident was noted as missing from the facility during a medication administration time. The facility Administrator was notified on 4/25/2020 at 8:45 PM and Resident #1 was returned to the facility on [DATE] at 9:15 PM. Resident #1's family was notified of the elopement and the Nurse Practitioner (NP) on call was notified. The nurse's note indicated a body audit was completed on Resident #1 and did not identify any injuries and the resident was placed on 15-minute safety checks. On 4/29/2020 at 2:00 PM, Resident #1 was observed wandering in the hallway of the facility. Resident #1 was carrying a clipboard and was pacing in between the dining room area and the nurse's station. At the time of the observation, Resident #1 was wearing a wander guard device on his/her left wrist. An interview on 4/30/2020 at 2:00 PM with Licensed Practical Nurse (LPN) #1 confirmed Resident #1 frequently wandered throughout the facility. LPN#1 stated he/she reported Resident #1 missing on 4/25/2020 after he/she went to the resident's room to administer medications. LPN#1 stated that the facility did not have any specific timeframes to check Resident #1's whereabouts prior to the incident on 4/25/2020. In addition, LPN#1 stated he/she notified facility staff and the facility Administrator that Resident #1 was missing. LPN#1 stated Resident #1 was assessed when returned to the facility on [DATE] at 9:15 PM. Resident #1 did not show any signs of distress or any injury as a result of the elopement. An interview on 4/30/2020 at 2:30 PM with Certified Nursing Assistant (CNA) #1 confirmed he/she was assigned to provide care to Resident #1 on 04/25/20. CNA#1 stated s/he was not aware of any specific timeframes to check the whereabouts of Resident #1 or other residents. CNA#1 stated, just know to keep up with them. CNA#1 stated s/he assisted with the search for Resident #1 on 04/25/2020, but could not recall if the kitchen door was locked. CNA#1 stated s/he last saw Resident #1 approximately 30 minutes prior to being alerted that s/he was missing. An interview on 4/30/2020 at 3:09 PM with LPN#2 confirmed she/he was working on 04/25/2020 when Resident #1 eloped from the facility. LPN#2 stated s/he assisted in the search for Resident #1 after being alerted the resident was missing. LPN#2 stated s/he did not notice whether the kitchen doors were unlocked or whether the exterior exit door in the kitchen area was unlocked when Resident #1 went missing. LPN#2 stated s/he was familiar with Resident #1's wandering behavior and stated, (Resident #1) frequently wanders throughout the building. LPN#2 further stated Resident #1, commonly walks toward the exits of the facility, sets off the door alarms and has to be redirected by staff. An interview on 4/30/2020 at 5:00 PM with the Director of Nursing (DON) confirmed Resident #1 had wandering behaviors and the Wandering Risk Scale assessment was completed when the resident was admitted . The DON confirmed s/he did not complete an Elopement Risk Assessment per the facility policy when Resident #1 was admitted because s/he did not have any occurrences of elopement. An interview was conducted with the facility Administrator on 4/30/2020 at 6:15 PM. The Administrator stated he returned Resident #1 to the facility on [DATE] at approximately 9:15 PM. The Administrator stated s/he did not notice any injuries to the resident upon return and instructed the nursing staff to assess Resident #1 and to begin 15-minute safety checks of Resident #1. The Administrator confirmed the wander guard device worn by Resident #1 was working properly at the time the resident was returned to the facility because the device, set off the alarm when Resident #1 re-entered the facility. In addition, the Administrator stated the facility investigation concluded Resident #1 eloped through the interior and exterior doors located in the kitchen area of the facility because the doors are the only unalarmed doors in the facility. Review of the facility's policy titled Elopement Management dated 07/2017 revealed, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safety interventions to minimize elopement risk. Signaling devices may be used, if available, and determined to be an appropriate intervention. The Interdisciplinary Team (lDT) evaluates each resident to identify elopement risk. A Care Plan is developed and implemented based on this evaluation, with ongoing review. Care Kardex's are updated and communicated to staff. The Administrator and Director of Nursing are responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, and monitoring of exit-seeking behavior. The goal of the Elopement Management System is to identify residents with potential exit-seeking behavior, to assure the Care Plan and Kardex reflect effective and consistent interventions and safety measures, and to assure staff are educated regarding the Elopement Management System and resident specific interventions. The policy further indicated under Policy Guidelines: #4. Residents assessed on admission with the risk for elopement will have; a. interventions implemented to promote safety; and b. Preventative measures implemented to mitigate elopement risk. The Immediate Jeopardy Removal Plan included the following: Summary of Incident: The facility admitted Resident #1 on 03/06/2020 with [DIAGNOSES REDACTED]. The facility placed a wander guard device on Resident #1 at the time of the resident's admission to the facility. On 04/25/2020 at 8:15 PM, Resident #1 eloped from the facility and was found at a nearby residence and returned to the facility approximately an hour later and immediately placed on 15-minute safety checks. On 4/25/2020 at 9:00 PM, the exterior door located in the kitchen area of the facility was locked. On 4/25/2020 at 9:20 PM, Resident #1's wander guard device was determined to be working. In addition, the alarms on the exit doors of the facility were determined to be working properly. On 4/26/2020 at 1:00 PM, a temporary alarm was installed on the exterior door in the kitchen area of the facility and a permanent alarm was ordered. The permanent alarm will be installed upon delivery to the facility on [DATE]. On 4/27/2020, Resident #1's care plan was updated to reflect the elopement incident and the 15-minute safety check intervention was added to the care plan. On 5/01/2020 at 4:30 PM, Resident #1 was placed on one-to-one (1:1) supervision until the permanent alarm is installed on the exterior door in the kitchen area of the facility. The estimated delivery and installation of the permanent alarm is 5/04/2020. For other residents assessed to be a risk, the facility has initiated the following steps: New Wandering Assessments and Elopement Risk Assessments were completed for all residents in the facility to determine if they were accurately assessed and documented related to each residents' risk of elopement and level of exit-seeking behavior. This was completed on 5/01/2020 at 12:30 PM. The facility has initiated the below education plan for all admission, social services, and licensed nursing staff. The facility's Elopement Management policy was revised on 5/01/2020 at 12:30 PM to include the supervision of residents with increased behaviors/exit seeking behaviors. 34 of 40 facility staff member were trained on the management of exit seeking behavior by the DON. All facility staff will be required to be educated prior to being placed on the schedule and prior to being allowed to work. All newly hired facility staff will be required to be trained during orientation and prior to beginning work in the facility. This was completed on 5/01/2020 at 12:30 PM. Monitor removal plan outcomes: On 4/25/2020 at 9:20 PM, the facility implemented daily safety checks to be completed by the Maintenance Director to ensure door alarms and wander guard devices used by residents are working properly. Elopement Drills were initiated on 4/30/2020 at 7:20 AM and will continue to be conducted at the facility on a weekly basis for four weeks through the week of 5/20/2020. Monthly Elopement Drills will be conducted during the months of June 2020 and July 2020. This will be completed no later than 7/31/2020. On 4/30/2020 at 8:50 PM, the facility implemented random monthly chart audits to be completed by the facility's Corporate Regulatory Consultant related to the behavioral care plans of residents receiving care and services. The facility's Consultant will complete 15 random chart audits for a 90-day period beginning on 5/01/20. The results of the safety checks of the alarms, the Elopement Drills, and the random chart audits will be reported to the facility's Quality Assurance Performance Improvement (QAPI) team on a monthly basis. On 5/01/2020 at 4:30 PM, the facility's Immediate Jeopardy Removal Plan was accepted, and the Removal Plan was determined to be fully implemented on 5/01/2020 at 5:00 PM.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure for one of three sampled residents (Resident #1) an elopement risk assessment completed on admission to the facility. This failure contributed to the elopement of Resident #1 on 04/25/2020 at 8:15 PM. This failure also has the potential to negatively affect the four residents in the facility who exhibit exit seeking behavior. Findings include: The facility admitted Resident #1 on 03/06/2020 with [DIAGNOSES REDACTED]. Review of the admission Wandering Risk Scale dated 03/06/2020, located in the electronic medical record (EMR) indicated Resident #1 was a wandering risk. The baseline care plan dated 03/09/2020 revealed Resident #1 was an elopement risk. Interventions included the use of a wander guard device (a device used to alert staff when a resident attempts to exit the building) and use of verbal redirection from staff. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/13/2020, indicated Resident #1 had a Brief Interview of Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment, was independent for ambulation, and used a wander guard device on a daily basis. On 4/25/2020 at 8:15 PM, Resident #1 eloped from the facility through an unsecured exterior door that was not alarmed. Resident #1 was located and returned to the facility at approximately one hour later. A review of Resident #1's assessments in the medical record revealed the facility did not complete an elopement assessment until 4/27/2020 after the elopement incident on 4/25/2020. On 4/29/2020 at 2:00 PM, Resident #1 was observed wandering in the hallway of the facility and was wearing a wander guard device on his/her left wrist. An interview was conducted with the MDS Coordinator on 04/30/2020 at 4:48 PM. The MDS Coordinator stated the Director of Nursing (DON) is responsible to complete elopement risk admission assessments to determine the elopement risk of residents when admitted . The MDS Coordinator confirmed Resident #1's MDS indicated the resident was identified as an elopement risk and Resident #1 was required to wear a wander guard device at all times. An interview was conducted with the DON on 04/30/2020 at 5:00 PM. The DON stated she used the Wandering Risk Scale assessment to assess Resident #1 at the time of the resident's admission because Resident #1 did not have any occurrences of elopement but did have wandering behaviors. The DON confirmed s/he did not assess Resident #1 for elopement risk at the time of admission per the facility policy. The DON stated s/he should have completed an Elopement Risk Assessment when Resident #1 was admitted . Review of the facility's policy titled Elopement Management, dated 07/2017 revealed, . Policy Guidelines: #1. Upon admission and readmission, residents will be assessed for elopement risk by completion of the Elopement Risk User Defined Assessment (UDA) in the electronic medical record in conjunction with the Nursing Admission Data Collection Set. In addition, the Policy Guidelines state: .#4. Residents assessed on admission with the risk for elopement will have; a. interventions implemented to promote safety; and b. Preventative measures implemented to mitigate elopement risk .

Based on record review, staff interview, review of a facility letter provided to employees and review of a facility policy entitled Reportable Diseases, the facility failed to have an Infection Control Plan for COVID-19 that included policies and procedures regarding implementing the appropriate transmission based precautions for residents with suspected or confirmed COVID-19; extending the supply of Personal Protective equipment as needed; guidance for use of cloth masks by Health Care Providers; initial fit testing of N95 masks; and when the State and Local Health Department should be contacted. This failure occurred during a COVID-19 pandemic. The findings included: Review of the Antibiotic and Infection Monitoring documentation provided by the facility for March 1 - April 21, 2020 revealed no residents with suspected or confirmed COVID-19. Random observations on 4/21/20 between 10:30 a.m. - 12:30 p.m. revealed that all observed staff were wearing face masks. Some staff has surgical masks while others had cloth face masks including Nurse #1. The facility's Infection Control Plan including policies and procedures for undiagnosed respiratory illness and COVID-19 was requested but a written plan was not available. In addition, the facility did not have a policy or procedure that specified local/state public health officials would be notified if there were clusters of respiratory illness or cases of COVID-19 that were identified or suspected. During an interview with the Administrator and the Director of Nursing (DON) on 4/21/20 at 11:00 a.m., the Administrator indicated the facility did have N95 masks for airborne precautions that they planned to use only for COVID-19 positive residents but did not have a fit testing plan. The Administrator and DON indicated they were aware that contact precautions (gown and gloves) should be implemented for residents with respiratory symptoms but were unaware that in addition to a face mask, eye protection should be used to ensure droplet precautions (mask and eye protection) were in place for residents with symptoms of COVID-19/suspected COVID-19 and any Person Under Investigation (PUI) for COVID-19; not just for COVID-19 positive residents. The facility had seven (7) face shields. Upon inquiry the Administrator and DON acknowledged they had not developed a plan for extending the supply of face shields or provided guidance to staff on how to sanitize face shields for reuse when droplet precautions needed to be implemented. They added that they had implemented universal staff use of face masks very early in March before the recommendation to use them came out. The Administrator also said that staff were allowed to choose to wear a cloth face mask instead if they wanted to. During an interview with the Administrator and the DON on 4/22/20 at 8:30 a.m., the Administrator acknowledged they did not have written policies and procedures related to the requirements for managing residents with symptoms of COVID-19 or confirmed COVID-19; how the facility planned to use and extend the supply of Personal Protective Equipment (PPE); guidance for staff on reprocessing PPE; use of cloth masks for Health Care Providers, criteria for discontinuing transmission based precautions; and when the State and Local Health Department should be contacted. The DON revealed she had been unaware that the State and Local Health Department needed to be contacted for a single suspected or confirmed case of COVID-19; instead of waiting for a cluster of cases or respiratory symptoms. Review of a letter to the facility employees dated 3/12/20 revealed (Name of Facility) is following the recommendations of the CDC (Centers for Disease Control) on using basic contact precautions to prevent the spread, which includes wearing gowns and gloves when interacting with residents who present symptoms-as we always do. Further review of this letter revealed there was no guidance to staff indicating droplet precautions (mask and eye protection) should also be initiated, along with airborne precautions (N95 mask) when possible. Review of a facility policy entitled Reportable Diseases dated 2012 revealed, Health Care Facilities are required by law to report certain diseases. A list of these diseases and the report forms are maintained and reporting is done as required.

Based on record review, review of facility policy and interview the facility failed to evaluate for fall risk for Residents #2, #11, and #16, 3 of 3 sampled Residents reviewed for Accidents. The residents received a Fall Risk Assessment on admission to the facility, then received no further Fall Risk Assessments despite multiple falls. The findings included: The facility admitted Resident #16 on 1/18/19 with [DIAGNOSES REDACTED]. Record review of Resident #16's Fall Risk assessments on 6/10/19 at 8:50 AM, revealed the resident had a Fall Risk Assessment on 1/18/19. The resident was assessed as a low fall risk. The resident had no additional Fall Risk Assessments. Record review of Resident #16's progress notes on 6/10/19 at 8:51 AM, revealed the resident had falls on 4/19/19 with a skin tear to the elbow, 4/22/19 with an abrasion to the elbow, 4/25/19 with no injury and 5/1/19 with no injury. The resident's Fall Risk was not re-assessed after the falls. Review of the Incident Reports for Resident #16 on 6/10/19 at 1:49 PM, revealed the falls were investigated and interventions were implemented related to the resident's falls. Review of the facility's Fall Management policy on 6/10/19 at 11:20 AM, revealed All residents will be assessed for risk quarterly, annually and for significant change using the Fall Risk Assessment. During an interview with Licensed Practical Nurse (LPN) #1 on 6/10/19 at 2:26 PM, LPN #1 stated that after a resident fall s/he would complete an Incident Report, a nurse's note, notify the physician and responsible party and complete a Fall Risk Assessment. During an interview with the Director of Nursing (DON) on 6/10/19 at 2 :58 PM, the DON initially stated Fall Risk Assessments should be done within 3 days of a fall and quarterly, as well. The DON also stated the facility has not been doing Fall Risk Assessments since 3/31/19 because the facility implemented a new Fall Risk Assessment on the electronic medical record and they hadn't started using that form yet. The DON then stated Fall Risk Assessments are not required to be done after each fall but required on admission and quarterly. The DON confirmed the resident had no further Fall Risk Assessments since admission. The DON confirmed the resident was assessed as a low fall risk on admission. During an interview with the DON on 06/11/19 at 03:39 PM, the DON was asked why residents were not receiving Fall Risk Assessments at least quarterly, the DON stated she did not know. When asked how the facility knows if a resident's risk for falls increases or decreases, the DON stated they would know based on increased or decreased falls, by changes in status and by doing a Fall Risk Assessment. The DON also stated the facility used to have a Risk Management meeting every Friday to review falls, but this group stopped meeting at the end of (MONTH) 2019 after the facility was acquired by new ownership. The DON stated the meetings were used to review falls, documentation, interventions and fall risks. During an interview with Registered Nurse (RN) #1 on 6/12/19 at 10:21 AM, RN #1 stated s/he had just initiated a performance improvement project (PIP) for post fall follow-up and care planning. A copy of the PIP was provided. The PIP was not dated as to when it was initiated, when corrective actions were put in place and when changes and education occurred. Review of the PIP revealed, as part of corrective action, the facility would complete Fall Risk Assessments within 48 hours of falls. The facility admitted Resident #11 on 10/5/16 with [DIAGNOSES REDACTED]. Review of Fall Risk Assessments for Resident #11 on 6/11/19 at 12:14 PM, revealed the resident had an annual Fall Risk Assessment on 10/24/17. The resident scored as a high fall risk. No additional Fall Risk Assessments had been completed. Record review of the Incident Reports for Resident #11 on 6/11/18 at 3:08 PM, revealed the resident had falls with no injuries on 2/8/19, 2/28/19, 3/17/19, 4/13/19 and 5/13/19. The falls were investigated, and interventions were implemented related to the resident's falls. During an interview with the DON on 06/11/19 at 03:39 PM, the DON confirmed Resident #11 had no Fall Risk Assessments since 10/24/17. When asked how nurse aides know which residents are a high fall risk, the DON stated they are given a verbal report on who is at risk and by the care plans. During an interview with Certified Nursing Assistant (CNA) #1, on 6/11/19 at 3:51 PM, CNA #1 stated s/he is given verbal report on who is a fall risk and it should also be noted on the care plan. The facility admitted Resident #2 on 11/27/17 with [DIAGNOSES REDACTED]. Review of Fall Risk Assessments for Resident #2 on 6/11/19 at 2:24 PM, revealed the resident had no Fall Risk Assessments since 11/28/17. The resident scored as a high fall risk. Review of the Incident Reports on 06/11/19 at 02:19 PM, revealed on 5/13/19 the resident was coming out of the bathroom in sock feet, slipped and fell to the floor with no injuries. An investigation was completed, and interventions were implemented. During an interview with the DON on 06/11/19 at 03:39 PM, the DON confirmed Resident #2 had no Fall Risk Assessments since 11/28/17.

Based on record review and interview, the facility failed to implement the Care Plan for 1 of 1 sampled resident reviewed for pressure ulcers. Skin care and pressure ulcer treatments were not provided per the Care Plan for Resident #37, resulting in a Stage IV pressure ulcer. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the 2/25/2015 Weekly Pressure Ulcer Record on 3/4/2015 at 12:06 PM revealed that Resident #37 acquired a new pressure ulcer to the sacrum with an onset date of 2/20/2015. The Pressure Ulcer was identified as a Stage IV Pressure Ulcer. Review of the Care Plan on 3/4/2014 at 11:30 AM revealed an intervention for the Pressure Ulcer to: "Administer treatments as ordered and observe for effectiveness." Another problem area on the Care Plan was the potential for impaired skin integrity "r/t (related to) incontinence episodes, catheter, [MEDICAL CONDITION], and decreased mobility." A listed intervention for this problem was "tx (treatment)/care of cyst per physicians orders." Review of the physician's orders [REDACTED]. Pack with normal saline gauze and apply [MEDICATION NAME] adhesive. Change qd (daily) and prn (as needed)." Further review of the physician's orders [REDACTED]. "Apply dry dressing over area on sacrum everyday and prn soiling one time a day for cyst." This treatment started 11/6/2014. 2. "Apply Calazyyme cream to area on buttocks below the coccyx every night shift for irritation (of the skin)." This treatment started 9/1/2014. The Calazyme cream treatment was not listed as an intervention on the Care Plan. Review of the Treatment Administration Record (TAR) on 3/4/2015 at 11:05 AM revealed that pressure ulcer treatments (start date 2/20/2015) were not documented as done daily as ordered on February 20, 23, 24, 26, 27, and 28, 2015. The treatment for [REDACTED]. Eighteen of 28 daily treatments for the cyst were not done in February, 2015. Three daily treatments for the cyst to the sacrum were not documented as done in December, 2015. treatment for [REDACTED]. The Calazyme cream to the buttocks was also not documented as done daily as ordered. The documentation noted that the Calazyme cream was applied to the buttocks on only 10 of 28 days in February, 2015. During an interview on 3/4/2015 at 1:41 PM, the Director of Nursing (DON) confirmed that the daily pressure ulcer treatment had not been documented as done daily as ordered and per the Care Plan. S/he confirmed that the treatment for [REDACTED]. The DON verified that the Calazyme cream for skin irritation was not listed on the Care Plan and not documented as done daily as ordered..

Based on record review, interview and review of the facility policy entitled "Skin Management Program", the facility failed to provide treatments and services to prevent development of a Stage IV pressure ulcer for 1 of 1 sampled resident reviewed for pressure ulcers. The facility failed to complete weekly skin audits and provide skin treatments as ordered for Resident #37, resulting in the Stage IV ulcer. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the 2/25/2015 Weekly Pressure Ulcer Record on 3/4/2015 at 12:06 PM revealed that Resident #37 acquired a new pressure ulcer to the sacrum on 2/20/2015. The pressure ulcer was identified as Stage IV. Review of the Physician's Orders on 3/4/2015 at 10:43 AM revealed a 2/20/2015 treatment order to: "Clean open areas to buttocks. Pack with normal saline gauze and apply [MEDICATION NAME] adhesive. Change qd (daily) and prn (as needed)." Further review of the Physician's Orders revealed the following treatment orders: 1."Apply calazyyme cream (a skin protectant) to area on buttocks below the coccyx (tail bone area) every night shift for irritation (of the skin)." This treatment started 9/1/2014. 2. "Apply dry dressing over area on sacrum everyday and prn soiling one time a day for cyst." This treatment started 11/6/2014. Review of the Care Plan on 3/4/2014 at 11:30 AM revealed a problem of "(Resident #37) has pressure ulcer (to) buttocks or potential for pressure development r/t (related to) Immobility, poor nutrition." Interventions included: 1. "Administer treatments as ordered and observe for effectiveness." 2. "Complete a full body check weekly and document." Another problem on the Care Plan for this resident was the potential for impaired skin integrity "r/t incontinence episodes, catheter, [MEDICAL CONDITION], and decreased mobility." A listed intervention for this problem was for "tx (treatment)/care of cyst per physicians orders." Calazyme cream to the buttocks was not listed as an intervention on the Care Plan. Review of the Treatment Administration Record (TAR) on 3/4/2015 at 11:05 AM revealed that pressure ulcer treatments (start date 2/20/2015) were not documented as done daily as ordered on February 20, 23, 24, 26, 27, and 28, 2015. Further review revealed that the Calazyme cream to the buttocks had not been documented as done daily as ordered on 18 out of 28 days in February, 2015. In addition, the treatment for [REDACTED]. 3 daily treatments for the cyst to the sacrum were not documented as done in December, 2015. treatment for [REDACTED]. Review of the weekly Head to Toe Skin Checks on 3/4/2015 at 12:28 PM revealed that the skin audits had not been done weekly. The weekly Head to Toe Skin Check was documented as done 1 time in December (12/6/2014) and 1 time in January (1/14/2015). The weekly skin check was not documented as done in February, 2015 prior to identifying the Stage IV Pressure Ulcer. During an interview on 3/4/2015 at 1:41 PM, the Director of Nursing (DON) confirmed that the weekly Head to Toe Skin Checks should have been done and were not documented as done weekly. S/he confirmed that the daily pressure ulcer treatment had not been documented as done daily as ordered. In addition, the DON confirmed that the treatment for [REDACTED]. Review of the facility policy entitled "Skin Management Program" on 3/4/2015 at 2:45 PM revealed that newly identified residents with skin breakdown should have weekly skin checks.